Fillable POWER OF ATTORNEY THAT Employer Registration Number having (ADP)

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POWER OF ATTORNEY THAT Employer Registration Number having (ADP)

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POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
THAT Employer Registration Number
having its principal office
does hereby appoint
at
before the NEW JERSEY
its true and lawful attorney in fact with full power and authority to represent the said
DIVISION OF EMPLOYER ACCOUNTS
until further notice, to wit: All matters affecting quarterly contributions reports, experience rating and
claims for benefits.
THIS AUTHORIZATION CANCELS AND SUPERSEDES ALL PRIOR POWERS OF ATTORNEY.
IN WITNESS WHEREOF, the said
has caused this instrument to be signed, sealed and acknowledged by its duly
day ofauthorized qualified officer this
(Name of Company)
CORPORATE SEAL By
(Signature of Authorized Officer)
(Name and Title of Authorized Officer)
AFFIDAVIT:
being duly sworn depose and say that I hold the office of
I
, in the I Employer
and am fully authorized on behalf of such
Registration Number
having its principal office at
as the true and lawful attorney in fact with power
company to grant the powers stated in said Power of Attorney to
before the NEW JERSEY DIVISION OF EMPLOYER ACCOUNTS without
and authority to represent
first obtaining the direction and approval of the Board of Directors of
(Signature of Authorized Officer)
notary public for this State
before me
Be it known that on this day of
I
residing in the county of
of
, duly commissioned and sworn and by law authorized to administer oaths and
and being sworn by me did depose and say that the contents in the foregoing
affirmations, personally appeared
affidavit are true and correct.
Notary Public
Notary Expiration:
(NOTARY SEAL)
ACCEPTANCE:
being a duly qualified officer of
hereby accept on behalf of the
I
said corporation the power herein described granted by
:
Title:
Authorized Agent Reg No.: ___________________________________________
,
.
__
Signature
Clear Form
State of New Jersey
PRINT
SAVE
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP New Hampshire.
The corporate seal is required unless the
employer is an individual or a partnership.
If no corporate seal, write NO SEAL.
This message will not print
OFFICER SIGNATURE REQUIRED
ADP, LLC, and its subsidiaries
and Corporate Cost Control, LLC.
OFFICER SIGNATURE REQUIRED
TO BE COMPLETED BY ADP
Corporate Cost Control, LLC.
TO BE COMPLETED BY ADP
TO BE COMPLETED BY ADP
0000-0043-3573
NEW JERSEY TEMPORARY DISABILITY INSURANCE MAILING ADDRESS
The next page is an optional form but is recommended that it be completed at the same time as
the Unemployment Benefits Power-of-Attorney. By completing the attached form you will ensure
that disability benefit documents will be mailed to the correct address avoiding unnecessary
delays in review and processing.
The State of New Jersey Division of Temporary Disability Insurance will often change the
mailing address of Disability documents in error when executing a Power-of-Attorney for
Unemployment Benefit matters.
A separate document is required for each Federal Employer Identification Number (FEIN).
Please review the NEW JERSEY TEMPORARY DISABILITY INSURANCE MAILING
ADDRESS form and return to ADP Unemployment Claims along with the Unemployment
Benefits Power-of-Attorney. ADP Unemployment Claims will file the form on your behalf.
If you have any questions regarding Temporary Disability issues contact the New Jersey
Division of Temporary Disability Insurance Employer Charge Unit at (609) 984-3747.
NEW JERSEY TEMPORARY DISABILITY INSURANCE CURRENT MAILING ADDRESS
We have recently received information indicating that your company may have had an address
change. New Jersey Temporary Disability Insurance mailings can be sent to an address that is
different from the one that is used for your Employer’s Quarterly Report (NJ927). In addition, you
can designate one mailing address for your Notice of Disability Benefits Charged or Credited
(DS-7C) and another mailing address (or multiple addresses) for your wage request forms and
determination notices.
If you wish to change your mailing address you must complete the items listed below:
1. Employer Name: ______________________________________________________________
Federal Employer Identification Number: ___________________________________________
2. Please give your address as you would like it to appear on your Employer’s Quarterly Report
(NJ927).
3. I would like to have my mailing address for New Jersey Temporary Disability wage requests and
determination notices changed to: (you may enter multiple addresses per FEIN)
4. I would like to have my mailing address for the Notice of Disability Benefits Charged or Credited
(DS-7C) changed to: (enter only one address per FEIN)
________________________________________________________
___
________________________________________________________________________
__
_
________________________________________________________________________
Return the completed form to the address listed below or fax it to (609) 292-5059.
Division of Temporary Disability Insurance
PO Box 387
Trenton, NJ 08625-0387
If you have any questions, please contact the Employer Charge Unit at (609) 984-3747.
IMPORTANT: A request to change a Temporary Disability Insurance address will not affect your tax
file address of record or an exception address for Unemployment Insurance. If you have any
questions regarding your tax file address, contact the Division of Revenue, Client Registration Section
at (609) 292-1730.
Signature: ________________________________ Date: __________________________________
Title: _______________
_
________ Telephone: ______________________Fax:_______________
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POWER OF ATTORNEY THAT Employer Registration Number having (ADP)

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Completed 8 February 2021

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