Fillable Power of Attorney N ew York State Department (ADP)

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Power of Attorney N ew York State Department (ADP)

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N
ew York State Department of
Labor
Unemployment Insurance (UI)
Division
Power of Attorney
For office use only
POA #:
Initials:
Read the Instructions for Filing a Power of Attorney, (IA 900.1), before you complete this form. They:
•
Explain how to complete this form and
•
Define the extent of the powers being granted
1. Employer
information
Employer legal name
UI Employer Registration Number
Mailing address
Federal Identification Number
City, village, town or post office State Zip code
2.
Power of Attorney (POA) information (List only one POA per form)
Firm name Contact name Mailing address Phone and fax numbers
I appoint the above named to represent me for the following designated purposes:
a) All UI matters
Check this box if you checked box a) above and want your mail sent to the POA address listed above
b) UI matters limited to contribution rates, elements used to calculate UI rates and under/overpayment information
c) Filing agent matters limited to contribution rates and account under/over payment information
d) UI benefit claim matters limited to information specific to a claim for UI benefits filed against my UI employer account
e) UI matters limited to acting on my beha
lf with a UI Employer Services Representative regarding audits,
investigations and enforcement actions
f) UI matters limited to acting on my behalf for UI Administrative Proceedings and Court Appeals
My representative is also authorized to receive disclosures of, and review and inspect confidential Federal tax information
and to perform any and all acts that I (we) can perform with respect to those tax matters as they bear on unemployment
insurance matters.
Note: Confidential Federal tax information shall include any and all information provided to the Department by the Internal
Revenue Service.
3.
Retention/Revocation of prior power(s) of attorney
Filing this power of attorney automatically revokes all existing power(s) of attorney with any representatives authorized for
the same designated purposes with the UI Division. Previously filed power(s) of attorney for
other designated UI purposes
remain in effect with this Division unless you revoke them in writing.
4.
Employer’s signature
If the employer named above is other than an individual: I certify that I am acting in the capacity of a corporate officer, partner
(except a limited partner), member or manager of a limited liability company, or fiduciary on behalf of the employer. I have the
authority to execute this power of attorney on behalf of the employer. If the matter concerns an individual proprietorship the
owner must sign. If the matter concerns a partnership, LLP, LLC, corporation or other entity the individual signing the consent
must have the authority to bind the entity. If signed by a corporate officer, partner, member, guardian, tax matters partner,
executor, receiver, administrator, or trustee on behalf of the employer, I certify that I have the authority to execute this form on
behalf of the employer.
Signature Employer’s phone and fax numbers Date
Print the name of the person signing this form if not the employer(s) named above Title, if applicable
Affix corporate seal if applicable
IA 900 (09/15)
Clear Form
PRINT
SAVE
ADP, LLC, and its subsidiaries and
Corporate Cost Control, LLC.
The parties may be addressed
collectively as ADP New Hampshire.
ADP Unemployment Claims
PO BOX 1390
LONDONDERRY NH
03053-1390
NOTARIZATION REQUIRED ON NEXT PAGE
5. Acknowledgment of the power of attorney
You must have this Power of Attorney witnessed before a notary public unless the appointed representative is licensed
to practice in New York State as an attorney-at-law, certified public accountant, or public accountant, or is a New York State resident
enrolled as an agent to practice before the Internal Revenue Service.
The person(s) signing as the above employer appeared before me and executed this power of attorney.
Acknowledgment — individual
State ___________________ S
S: _______________________
County of __________________________________________
On this ___________________ day of ___________________
before me personally came, ___________________________
to me known to be the person(s) described in the foregoing
Power of Attorney; and he/she/they acknowledged that
he/she/they executed the same.
Notary Signature Date
Stamp
Acknowledgment — corporate
State _______________________ SS: ________________________
County of _______________________________________________
On this ________________________ day of ___________________
before me personally came, ________________________________
to me known, who, being by me duly sworn, did say that he/she
resides at (insert address) __________________________________
that he/she is the _________________________________________
of _____________________________________________________
the corporation described in
the foregoing Power of
Attorney
; and that he/she/they Notary Signature Date
signed his/her/their name(s)
thereto by authority of the
board of directors of said
corporation.
Stamp
Acknowledgment — limited liability company
State ___________________ SS: _______________________
County of __________________________________________
On this ___________________ day of ___________________
before me personally came, ___________________________
to me known, who, being by me duly sworn, did say that
he/she/they/it reside(s) at (insert address) ________________
__________________________________________________
that he/she/they is (are) a member(s) or manager(s) of the
limited liability company
described in the
foregoing Power of Notary Signature Date
Attorney; and that
he/she/ they is (are)
empowered to and did
execute the same.
Stamp
Acknowledgment — partnerships/LLP
State _______________________ S
S: _______________________
County of _______________________________________________
On this ________________________ day of ___________________
before me personally came, ________________________________
to me known, who, being by me duly sworn, did say that
he/she/they/it reside(s) at (insert address) _____________________
________________________________________________________
that he/she/they/it is (are) a partner(s) of _______________________
________________________
the partnership described
in the foregoing Power of Notary Signature Date
Attorney; and that
he/she/they/it is (are)
empowered to and did
execute the same.
Stamp
6. Declaration of representative (to be completed by representative)
I agree to represent the above-named employer in accordance with this power of attorney.
I affirm that my representation will not violate
the provisions of the Ethics in Government Act or Section 2604(d) of the New York City Charter. These provisions restrict appearances by
former government employees before his or her former agency. I have read a summary of these restrictions in the instructions to this form.
I am (check all that apply and sign):
1. an attorney-at-law licensed to practice in New York State
4. an agent enrolled to practice before the Internal Revenue
Service PTIN#: ____________________
2. a certified public accountant duly qualified to practice in
New York State PTIN#: ____________________
5. an employee not a corporate officer (if the employer is a
corporation)
3. a public accountant enrolled with the New York State
Education Department PTIN#: ____________________
6. Other
Designation
(use number(s)
from above list)
Representative’s
Federal Identification Number (FEIN) or
UI Employer Registration Number
Signature
Date
IA 900 (09/15) back
NOTARIZATION REQUIRED
Unemployment vendor
6
46-5358523
to be completed by ADP
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Power of Attorney N ew York State Department (ADP)

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Completed 8 February 2021

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