ID 1200 ( revised) Power of Attorney form
Power of Attorney for Unemployment Insurance
This authorization allows the Employment Security Department to send or share confidential information about
your unemployment insurance account with your designated representative. Please complete all information below.
It must match the records we have on file for your business. *Employers must have an actual ESD account
number issued and listed on this form in order to submit for processing.
Section 1 – Employer information
Business name: ESD number*:
Business phone number: EIN:
Mailing address line 1: UBI number:
Mailing address line 2:
City: State: Zip code:
Employer contact name and title:
Contact phone number:
Contact email:
Section 2 – Representative for Tax purposes
Representative EIN (required):
Representative organization name:
Mailing address line 1:
Mailing address line 2:
City: State: Zip code:
Representative contact name:
Contact phone number:
Contact fax number:
Contact email:
Section 3 – Confidential tax information
Authorizations: Please select the boxes that indicate how much authority you’d like to give your representative.
Unemployment insurance tax reports and amendments
Tax payments and billing statements
Electronic access to information as available
Audit of unemployment insurance taxes
Enter into agreements
Represent and make oral or written presentations of fact and/or argument
Mailing tax documents:
Please select the address ESD should use when mailing tax documents. (mark ONLY ONE)
Employer’s mailing address. (
Use the Business Change Form to report any change of business address.)
Representative’s address in section 2 above
Mailing billings:
Please select the address ESD should use when mailing billings and payment notices. (mark ONLY ONE)
Employer’s mailing address.
(Use the Business Change Form to report any change of business address.)
Representative’s address in section 2 above
ADP and Corporate Cost Control
c/o ADP UNEMPLOYMENT CLAIMS
uidocs@adpunemploymentclaims.com
