Fillable Paid Family and Medical Leave power of attorney (Washington)

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Paid Family and Medical Leave power of attorney (Washington)

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The Paid Family and Medical Leave power of attorney (Washington) form is 2 pages long and contains:

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  • 5 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

BROWSE WASHINGTON FORMS

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Updated 7/12/2019
Paid Family and Medical Leave power of attorney
This authorization allows the Employment Security Department to send and share confidential Paid Family
and Medical Leave information about the business listed with the designated representative, known as the
employer agent (“agent”) below.
By law, the employer is liable for all acts taken or failure to act by the agent on the employer’s behalf for any
delegated roles assigned to the agent (WAC 192-500-015).
Both the employer and agent must complete and sign this form. All fields are required unless
otherwise specified.
Section One: Employer Information
Legal entity name:
Unified Business Identifier number:
Contact phone: Contact email:
Section Two: Agent Information
Note: Agents must register with Paid Family and Medical Leave to receive an employer agent ID. Go to
paidleave.wa.gov to log in and create your account.
Legal entity name:
Employer Identification Number (EIN):
Employer agent ID:
Contact phone: Contact email:
Section Three: Authorizations
Check the box(es) below indicating the level of authority you wish to grant to the agent; authority will
cover any correspondence related to these roles.
Wage reporting (filing quarterly wage reports)
Wage amendments (review wage detail history and make amendments)
Payments (view billing statements and make payments)
Audits (participate in Paid Family and Medical Leave audits)
Appeals and agreements (enter into agreements and make oral or written presentation of fact
and argument)
Updated 7/12/2019
Section Four: Effective Dates and Signatures
If you do not provide an end date for this agreement, the authorizations listed will remain in effect until
revoked in writing or through an alternate method authorized by the commissioner.
Effective start date: Effective end date (optional):
I, the undersigned, declare under penalty of perjury under the laws of the State of Washington
that I am the business owner or officer duly authorized to represent this account and further
declare that the information submitted has been examined by me and that the matters and
statements set forth are true, correct and complete.
Employer signature: Date:
Printed name:
Title:
I, the undersigned, declare under penalty of perjury under the laws of the State of Washington
that I, and any delegated individual representing my agency, am duly authorized to represent
this account. Further, I declare that the information submitted has been examined by me and
that the matters and statements set forth are true, correct and complete.
Agent signature: Date:
Printed name:
Title:
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Paid Family and Medical Leave power of attorney (Washington)

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Completed 28 January 2021

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