POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS:
THAT, ____
____________________________, GA DOL Account No. ___________________,
having its principal office at ______________________________________________, hereby
appoints ____________________________ as its true and lawful agent with full authority to
represent the said __________________________ before the Georgia Department of Labor,
until further notice, in connection with all matters affecting State Unemployment Insurance
Taxes including, without limitation, all claims, tax contributions and experience ratings.
This Power of Attorney supersedes and revokes any prior power of attorney authorization from
the named employer relating to the subject matter hereof. The undersigned warrants that he or
she is authorized to execute this Power of Attorney.
IN WITNESS WHEREOF, the undersigned has duly executed and delivered this Power of
Attorney on behalf of the named employer this _____ day of __________________ 20____.
___________________________________
Employer’s Name
By: ___________________________________
Signature
___________________________________
Print or Type Name
___________________________________
Title
It is respectfully requested that all forms pertaining to unemployment taxes be mailed to the new
ADDRESS OF RECORD as indicated below.
Georgia Department of Labor
ADP, LLC, and its subsidiaries and Corporate Cost
Control, LLC, to be known as ADP-CCC.
c/o ADP Unemployment Claims
PO BOX 16440
CLEARWATER FL 33766-6440
