Fill - Free fillable TEN AUTHORIZATION WRIT P.O. Box 995 Columbia, SC (ADP) PDF form

WRIT

TEN AUTHORIZATION

* If you are authorizing agent to submit wage reports, please note that DEW will make the effective date of that authorization retroactive to the beginning of the quarter in which the date you provide falls.

** If no “Endin

g Effective Date” is provided, the above-named agent will be authorized to represent you until you notify ETS in writing that you wish to change your agent.

Please read the instructions following this form before completing. By completing this form, you are authorizing the South Carolina Department of

Employment and Workforce (DEW) to disclose/discuss Unemployment Insurance (UI) related matters to your chosen agent. This form is only to be used to

designate an agent. If you are attempting to add or remove authorized contact persons, do not complete this form. Please refer to the attached instructions for

more information.

PART 1: EMPLOYER INFORMATION

Name and Address: (if individual)

If a business entity, enter DBA, trade or assumed name:

FEIN:

DEW Account #:

Telephone Number (required):

Extension:

Fax Number:

Email Address:

PART 2: AGENT INFORMATION AND AUTHORIZATION DATES

Your authorized agent may be an organization, firm, or individual. If your agent is not an individual, designate a contact person. Please ensure that you

submit a separate form for each agent. (NOTE: Only one agent can occupy each role during any given time period.)

Agent Name and Address

Contact Name (if applicable):

Agent FEIN (if any):

SUITS Agent Account #:

Telephone Number (required):

Extension:

Fax Number:

Email Address:

Beginning Effective Date (required)*:

Ending Effective Date – (Optional)**:

PART 3: TYPE OF AUTHORIZATION

GENERAL AUTHORIZATION

Authorizes my agent to: (1) submit wage reports, (2) submit payments and enter into payment agreements, (3) perform account maintenance

updates, (4) submit and receive information related to UI benefits. This authorization applies to all tax and benefit related matters.

LIMITED AUTHORIZATION

Select the type of authorization by checking the appropriate boxes to the right of each item listed below. You may check up to 3 boxes.

If 4 boxes apply, please complete the ‘General Authorization’ above.

1. Wage Submission (Original and Amended) ........................................................

2. Payment Submission and Payment Agreements ..................................................

3. Account Maintenance Updates ............................................................................

4. Benefits (UI Benefit related matters) ...................................................................

PART 4: AUTHORIZATION AND RELEASE FOR DISCLOSURE OF UI TAX AND/OR UI BENEFIT INFORMATION/RECORDS

I understand that any information or records obtained by DEW in the administration of the Unemployment Insurance program is generally private and confidential

pursuant to S.C. Code Ann. § 41-29-160 and 20 CFR Part 603, and may only be released for the purpose specified in this Written Authorization in accordance with

state and federal law. By signing this Written Authorization, I am authorizing DEW to release the information specified to the authorized agent. I understand state

government files will be accessed to obtain the information disclosed to the authorized agent. I further understand that I am authorizing the appointed agent to act on

behalf of the business to the fullest extent to which I could act if I were personally present in connection with the transactions authorized in Part 3 of this Written

Authorization. I further declare the information submitted has been examined by me and I specifically authorize agent(s) to transact the above specified UI business

with DEW.

Name (Print )_________________________________________________________________Title ________________________________________________________

Signature _________________________________________________________Date _________________ Phone No. _________________________________________

In order for this application to be processed, the signatory must be on file with DEW as a business owner, officer, partner or agent duly authorized to act on behalf of

this employer.

IMPORTANT: Completing this form will not

change an employer’s address of record.

Address changes must be made through

SUITS.

UCE-1010 (Rev. 12/7/18)

P.O. Box 995 Columbia, SC 29202

803-737-2400 | www.dew.sc.gov

Clear Form

SAVE

ADP LLC, and its subsidiaries and Corporate

Cost Control LLC

The parties may be addressed collectively as

ADP NEW HAMPSHIRE

PO BOX 16440

CLEARWATER FL 33766-6440

SIDES: BR000000022

ADP POA Coordinator

46-5358523

SC0A1U

855-537-8499

855-537-8536

UIDOCS@ADPUNEMPLOYMENTCLAIMS.COM

SIGNATURE REQUIRED ON BOTH PAGES

P.O. Box 995 Columbia, SC 29202

803-737-2400 | www.dew.sc.gov

EMPLOYER REPORT OF

CHANGE TO ACCOUNT

Visit SUITS, DEW’s online tax system at https://uitax.dew.sc.gov. For instructions on how to use SUITS, please visit https://dew.sc.gov/suits.

EMPLOYER INFORMATION

Business Name:__________________________________________ DEW Account Number:

___________________

FEIN:____________________

CHANGES TO ACCOUNT

Effective Date of Changes being made (mm/dd/yyyy):________________________

1. Add/Remove Owner/Officer (Individual changes within the organization which DO NOT change the entity.).

Name SSN Title Ownership % Home Address ADD or REMOVE

Add Remove

2. Change of Physical Location.

Storefront/Physical Location Job/Construction Site Employee Residence

(Location Address)

(City)

(State)

(Zip Code)

3. Change in Mailing Address.

(Address or PO Box)

(City)

(State)

(Zip Code)

4. Change in Legal Business Name to: _________________________________

5. Business in South Carolina continues in operation without employment.

6. Business in South Carolina suspended or entirely discontinued without successor.

7. Business in South Carolina acquired by successor.

If you checked 5 through 7, please explain below:

I CERTIFY THAT THE INFORMATION ENTERED ON THIS FORM IS TRUE AND ACCURATE, AND THAT I AM AUTHORIZED BY THE NAMED

EMPLOYING UNIT TO COMPLETE THIS REPORT. (In order for this form to be processed, the signatory must be on file with DEW as a business owner,

officer, partner or agent duly authorized to act on behalf of this employer.)

Name (Print )__________________________________________________________ Title ________________________________________________________

Signature _________________________________________________ Date ____________________ Phone No. _________________________________________

SCDEW

Document Control

PO Box 995

Columbia, SC 29202

UCE-101-S (Rev. 12/6/18)

Please attach the documents filed with

the Secretary of State verifying change.

PO BOX 16440

CLEARWATER

33766-6440

SIGNATURE REQUIRED ON BOTH PAGES

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TEN AUTHORIZATION WRIT P.O. Box 995 Columbia, SC (ADP)

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