EMPLOYER POWER OF ATTORNEY ASSIGNMENT                                                                   Department of Workforce Development 
                                                                                                          Unemployment Insurance Division 
                                                                                                                            P.O. Box 7942 
                                                                                                                Madison, WI 53707 
Be Aware That:                                                                                                              Fax: (608) 327-6158 

                                                             ,                                      ,                                       ,  
              (Employer Name)                                        (UI Account #)                         (FEIN #) 

having its main office located at                                                                                                           , 
                                                          (Street Address, City, State & Zip Code) 

                                   appoints                                                                                                 ,
(Telephone Number with Area Code)                                   (Name of Representing Company)

located at                                                                                           ,                                      , 
                 (Street Address, City, State & Zip Code)                                               (Telephone Number with Area Code) 
as its attorney or representative with full power to represent the employer before the Wisconsin Unemployment Insurance 
Division.  This representation applies to all matters affecting unemployment insurance including, although not limited to,  
all benefit claims, contributions, refunds, experience rating, hearings and appeals. 

The employer further understands the Wisconsin Unemployment Insurance Division maintains three (3) separate and 
distinct mailing groups *which include:  
    Group I                       UCB-16                       Separation Notice 
                                  UCB-23                       Wage Verification/Eligibility Report 
                                  UCB-20                       Determination 

    Group II                      UCT-14384-1-E                Unemployment Insurance Benefit Charges and Adjustments 

    Group III                     UCB-719                      Urgent Request for Wages 
                                  UCB-701                      Computation of Unemployment Insurance Benefits 
                                  UCB-708                      Notice of Changed Liability for UI Benefits 
                                  UCT-101-E                    Quarterly Contribution Report 
                                  UCT-14384-E                  Unemployment Insurance Reserve Fund Balance Statement 
                                  UC-7823-E                    Quarterly Wage Reports 
                                  UCT-14309-E                  Reimbursable Employer Monthly Statement 

* Forms listed above must remain within the respective mailing group

The employer authorizes group(s)                               to be mailed to the representative's address listed above. 
                                      (List Group Number(s)) 
The remaining group(s)                                      will be mailed to the employer's main office. 
                                  (List Group Number(s))
By the signatures below, the employer known as                                                                                              , 
                                                                             (Employer Name) 
approves the above directions and voluntarily enters into this assignment on                                                                , 
                                                                                                        (Date – mm/dd/yyyy) 
at which time this assignment is effective and takes place of all previous assignments. 

Authorized Signature:    
                         (Employer Signature)                                (Date Signed – mm/dd/yyyy) 
Printed Name & Title: 
                         (Print Name)                                        (Job Title) 
Witnessed By:  
                         (Witness Signature)                                 (Date Signed – mm/dd/yyyy) 
Printed Name & Title: 
                         (Print Name)                                        (Job Title) 

UCT-8291-E (R. 02/2018)