POWER OF ATTORNEY (POA) DECLARATION
SEE INSTRUCTIONS ON THE BACK OF THIS FORM.
I. EMPLOYER/TAXPAYER INFORMATION (please type or print)
California Employer Payroll Tax Account Number: (if applicable)
Federal Employer Identification Number:
Owner/Corporation Name: Corporate Identification Number:
Business Name/Doing Business As (DBA):
Business Mailing Address: City: State: ZIP Code:
Business Phone Number: Business Fax Number:
Business Location (if different from above): City: State: ZIP Code:
II. REPRESENTATIVE DESIGNATION (please type or print)
I hereby appoint the following person to represent the employer/taxpayer for specified tax matters arising under the
California Unemployment Insurance Code.
Representative’s Business:
Representative’s Name: Phone Number: Fax Number:
Business Mailing Address: City: State: ZIP Code:
III. AUTHORIZED ACT(S)
GENERAL AUTHORIZATION: If you want to give the representative general authority to perform all acts on your behalf
with regard to your state tax matters.
SPECIFIC DECLARATION: If you want to give the representative limited authority with regard to your state
From To tax matters, indicate the specific dates and acts you are authorizing.
To represent the employer/taxpayer for any and all
Tax Reporting Benefit Reporting Both matters relating to the reporting period indicated above.
To represent the employer/taxpayer for changes to their mailing address for any and all
Tax Reporting Benefit Reporting Both matters relating to the reporting period indicated above.
Other acts: (describe specifically)
Subject to revocation, the above representative is authorized to receive confidential information.
IV. SIGNATURE AUTHORIZING POWER OF ATTORNEY
Signature of the employer/taxpayer, owner, officer, receiver, administrator, or trustee for the employer/taxpayer: If you are
a corporate officer, partner, guardian, tax matters partner/person, executor, receiver, administrator, or trustee on behalf of the
employer/taxpayer, you are certifying that you have the authority to execute this form on behalf of the employer/taxpayer by
signing this Power of Attorney Declaration.
If this Power of Attorney Declaration is not signed and dated, it will be returned as invalid.
I certify under penalty of perjury that the above information is true, correct, and complete, and that these actions are not to be taken to
receive a more favorable Unemployment Insurance rate. I further certify that I have the authority to sign on behalf of the above business.
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Signature
Print Name
Title (Owner, Partner, Corp. Officer: Pres., Vice Pres., CEO or CFO)
DE 48 Rev. 9 (5-19) (INTERNET)
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Date
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ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC., known as ADP NEW HAMPSHIRE.
