Fillable POWER OF ATTORNEY UI FORM POA DEPARTMENT OF (ADP)

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POWER OF ATTORNEY UI FORM POA DEPARTMENT OF (ADP)

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UI FORM POA
Date Stamp
STATE OF NEBRASKA
DEPARTMENT OF LABOR
UNEMPLOYMENT INSURANCE
P O BOX 94600
LINCOLN, NEBRASKA 68509-4600
Phone: 402.471.9898
Fax: 402.471.9994
Website: dol.nebraska.gov/UIConnect
Employer Account Number
Federal Identification Number
Reviewed/Approved
DATE
POWER OF ATTORNEY
(NEB. REV. STAT. §48-607)
Business Name and Address
Department Functions Authorized with Power
of Attorney
Representative Mailing Address (Address, City, State, Zip) and
Email Address*
□
Quarterly Tax Report Filings
□
Quarterly Tax Report Mailings
□
Combined Tax Rate Notices
□
Benefit Claims/ Benefit Charging Notices
□
Benefit Payment Control Audits
□
Appeal Documents
□
SIDES
Broker ID # _______________________________
REVOCATION OF PRIOR POWERS OF ATTORNEY
□
I choose to revoke all prior powers of attorney on file with the Department with respect to the same Unemployment
Insurance activities listed above, except the following: _____________________________ effective ___________
□
I choose to revoke all powers of attorney on file with the Department effective ___________________________.
* The email address provided may be used for future Department official business.
Business Name
Doing Business As (DBA)
Phone Number
Mailing Address
City State Zip Code
Representative Name and Address
Representative Legal Name
Representative DBA Name
Representative Mailing Address
Phone Number
City State Zip Code
Representative E-mail Address*
The employer appoints the above entity for the purposes of representation for the following Unemployment Insurance matters as indicated below
(check applicable boxes). If representative does not have prior authority, indicate correct address.
If signed by an individual, corporate officer, partner, member, LLC manager, or fiduciary on behalf of the taxpayer/representative, I hereby certify that
I approve this Power of Attorney, who is authorized to execute the Power of Attorney on behalf of the taxpayer.
X
Signature of Business Owner
Date
Print Name Employer E-mail Address*
X
Signature of Power of Attorney
Date
Print Name
E-mail Address*
Title
ADP, LLC & its subsidiaries & Corporate Cost Control, LLC
ADP UNEMPLOYMENT CLAIMS
PO BOX 1390
855-537-8499
LONDONDERRY NH 03053-1390
uidocs@adpunemploymentclaims.com
PO Box 1390, Londonderry, NH 03053-1390
000000022
ADP TAX FILING
PO Box 1390, Londonderry, NH 03053-1390
PO Box 1390, Londonderry, NH 03053-1390
uidocs@adpunemploymentclaims.com
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POWER OF ATTORNEY UI FORM POA DEPARTMENT OF (ADP)

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Completed 8 February 2021

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