NORTH CAROLINA DEPARTMENT OF COMMERCE
DIVISION OF EMPLOYMENT SECURITY
POST OFFICE BOX 26504
RALEIGH, NC 27611-6504
POWER OF ATTORNEY
AND
DECLARATION OF REPRESENTATIVE
EMPLOYER NAME (Exactly as shown on Division of Employment Security records)
FEDERAL EMPLOYER IDENTIFICATION NUMBER
STATE UNEMPLOYMENT TAX ACCOUNT NUMBER
REPRESENTATIVE NAME
The above representative is appointed to represent the above-referenced employer in all matters
pertaining to contributions (tax) and benefits (claims). An agent appointed pursuant to this Power
of Attorney and Declaration of Representative may:
1. Complete and submit documents for filing employers’ tax and wage reports;
2. Complete and submit documents regarding an employer’s tax rate, contributions, and direct
reimbursements;
3. Respond to benefit claims documents, including responding to requests for information about
a claimant’s separation or status;
4. Engage in discussions with representatives of the Division of Employment Security regarding
the actions listed above; or
5. Accept or receive correspondence sent by DES regarding claims for benefits or an employer’s
contributions.
6. The undersigned employer acknowledges that the agent appointed pursuant to this Power of
Attorney and Declaration of Representative is not authorized to represent the employer in
hearings or to enter appeals except as authorized by N.C. Gen. Stat. § 96-17(b), and 04 N.C.
Admin. Code 24A .0109 and 04 N.C. Admin. Code 24A .0110.
7. The undersigned employer further acknowledges that its mailing address for tax matters will
remain unchanged, unless the employer submits a change of address in accordance with 04
N.C. Admin. Code 24A .0102.
( ) Link this employer to Claims Remitter No. ___________________.
( ) Add the representative’s address as a special claims address to this employer.
ADP,LLC and its subsidiaries and Corporate Cost Control, LLC. Collectively known as ADP-CCC.
