NORTH CAROLINA DEPARTMENT OF COMMERCE 
                     DIVISION OF EMPLOYMENT SECURITY 
                                         POST OFFICE BOX 26504 
                                         RALEIGH, NC  27611-6504 
                                           
                                         POWER OF ATTORNEY 
                                          AND 
                     DECLARATION OF REPRESENTATIVE 
                                           
 EMPLOYER NAME (Exactly as shown on Division of Employment Security records) 

 FEDERAL EMPLOYER IDENTIFICATION  NUMBER                                     STATE UNEMPLOYMENT  TAX ACCOUNT NUMBER 

 REPRESENTATIVE NAME 
  
 The above representative is appointed to represent the above-referenced employer in all matters 
 pertaining to contributions (tax) and benefits (claims).  An agent appointed pursuant to this Power 
 of Attorney and Declaration of Representative may: 
  
 1.  Complete and submit documents for filing employers’ tax and wage reports; 
 
 2.  Complete and submit documents regarding an employer’s tax rate, contributions, and direct 
  reimbursements; 
  
 3.  Respond to benefit claims documents, including responding to requests for information about 
  a claimant’s separation or status; 
  
 4.  Engage in discussions with representatives of the Division of Employment Security regarding 
  the actions listed above; or 
 
 5.  Accept or receive correspondence sent by DES regarding claims for benefits or an employer’s 
  contributions. 
 
 6.  The undersigned employer acknowledges that the agent appointed pursuant to this Power of 
  Attorney and Declaration of Representative is not authorized to represent the employer in 
  hearings or to enter appeals except as authorized by N.C. Gen. Stat. § 96-17(b), and 04 N.C. 
  Admin. Code 24A .0109 and 04 N.C. Admin. Code 24A .0110. 
 
 7.  The undersigned employer further acknowledges that its mailing address for tax matters will 
  remain unchanged, unless the employer submits a change of address in accordance with 04 
  N.C. Admin. Code 24A .0102. 
  
            (     )  Link this employer to Claims Remitter No. ___________________. 
  
            (     )  Add the representative’s address as a special claims address to this employer. 

                                                                                                                                                                                                           REVISED 10/2017 
 _____________________________________ 
 Representative Name 
 
 _____________________________________ 
 Address 
 
 _____________________________________ 
 City, State, Zip 
 
This Power of Attorney and Declaration of Representative shall become effective on the _______ 
day of ____________________________, ______, and shall remain in effect until revoked by the 
employer, the representative, or the Division of Employment Security. 
 
                              (SEAL) 
 
____________________________________                                                ______________________________ 
AUTHORIZING SIGNATURE                                                               TITLE 
(must be the proprietor, a general partner or duly elected corporate officer) 
 
______________________________________________________________________________ 
TYPED OR PRINTED NAME 
 
SUBSCRIBED AND SWORN to before me on this ____ day of _________________, ________. 
 
              ______________________________________________ 
              NOTARY PUBLIC 
 
(Notary Seal) 
              My Commission expires ______________________________, _______. 
 
____________________________________ 
REPRESENTATIVE NAME 
 
____________________________________                                          _______________________________ 
TYPED OR PRINTED NAME                                                         TITLE