Fillable REVOCATION AUTHORIZATION TO DISCLOSE INFORMATION, DESIGNATION OF ADDRESS (ADP)

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REVOCATION AUTHORIZATION TO DISCLOSE INFORMATION, DESIGNATION OF ADDRESS (ADP)

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AUTHORIZATION TO DISCLOSE INFORMATION,
DESIGNATION OF ADDRESS OF RECORD AND
REVOCATION
UNEMPLOYMENT INSURANCE
SFN 59128 (R 6-09)
Employer Information
Name of Employer
Telephone Number
FEIN
Name of Spouse, Fiduciary, or Personal
Representative (if applicable)
Telephone Number
FEIN
(if different than that of
employer)
Address
City
State
Zip Code
Designated Individual or Firm
Name of Individual or Firm
Telephone Number
FEIN
Address
City
State
Zip Code
Fax Number Email – Address
A. Authorization to Disclose Information
Job Service North Dakota is authorized to disclose confidential information relating to unemployment insurance (UI)
matters selected below to the designated individual or firm above.
UI Tax
UI Claims
All
This authorization takes effect upon receipt by Job Service North Dakota and remains in effect until revoked in writing
by the employer. The authorization does not cover the routine mailing of tax forms, refund checks, original notices (e.g.
Notice of Determination, Notice of Claim, etc.), or other original written communications.
B. Revocation
Job Service North Dakota is notified that the above-named employer hereby revokes the authorization to disclose
confidential information relating to selected unemployment insurance (UI) matters to the previously authorized
individual or firm. No new authorization is being made. (If this box is checked, Do Not Check Box A.) This revocation
takes effect immediately upon receipt by Job Service North Dakota.
C. Designation of Address of Record
Job Service North Dakota is notified that the above-named individual or firm is designated to be the address of record
(place to which correspondence is sent) with respect to unemployment insurance (UI) matters selected below.
UI Tax Correspondence
UI Claims Correspondence
All Correspondence
This designation takes effect upon receipt by Job Service North Dakota and remains in effect until revoked in writing by
the employer.
D. Revocation
Job Service North Dakota is notified that the employer hereby revokes the designation of address of record to the
above-named individual or firm, relating to unemployment insurance matters originally indicated. No new designation
is being made. (If this box is checked, Do Not Check Box C.) This revocation takes effect immediately upon receipt by
Job Service North Dakota.
Signature of Employer
If signed by a corporate officer, partner, governor, manager, or fiduciary on behalf of taxpayer, I certify I have authority
to sign this form on behalf of the employer.
For Office Use Only
Signature of Employer
Date
Printed Name Title
Job S
ervice North Dakota is an equal opportunity employer/program provider.
Auxiliary aids and services are available upon request to individuals with disabilities.
Job Service North Dakota
UI/Tax & Field Services
PO Box 5507
Bismarck ND 58506-5507
701-328-2814
Fax 701-328-1882
Toll-free 800-472-2952
TTY: Relay ND 800-366-6888
Clear Form
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP NH.
(855) 537-8499
PO BOX 17617
MISSOULA
MT
59808-7616
(855) 537-8536
uidocs@adpunemploymentclaims.com
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REVOCATION AUTHORIZATION TO DISCLOSE INFORMATION, DESIGNATION OF ADDRESS (ADP)

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Completed 8 February 2021

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