Declaration of Power of Attorney or Authorized Representative 
68-0092 (07-16) 

Power of Attorney or Authorized Representative may be assigned online @ www.myiowaui.org

1. Business granting Power of Attorney or Authorized Representative 

Legal Business Name:                                                                                             UI Account #:
DBA:                                                                                                                       FEIN:
Sole Proprietor Name 
(First, MI, Last):                                                                                                         SSN:
Mailing Address:
City:                                                                                  State/Province:   Zip+4/Postal Code:
Phone:                                                         Ext:

2.                                         Power of Attorneyor Authorized Representative
Effective Date:                                                                         End Date:

3. Power of Attorney or Authorized Representative Information
Firm or Legal 
Business Name:                                                                                                             FEIN:
Address:                                                                                                         Agent ID: R
City:                                                                                  State/Province:   Zip+4/Postal Code:
Phone:                                                         Ext:
Note: Each Power of Attorney or Authorized Representative needs to complete a separate form 68-0092

4. Assign agent roles -- See page 2 of instructions for description of roles
As the true and lawful agent, with limited power and authority to represent the said employer before IWD in only the matters selected below:        
Please check all boxes that apply. 

MyIowaUI.org Website Roles: (This applies to all reporting units)                                                Authorized Roles
 
 All Roles                                                     Submit/Change Wage Detail                         Check appropriate box below for  
                                                                                                                 communication purposes (if applicable)
 System Administrator                                          Wage Detail View Only
 Maintain Account                                              View Correspondence                               All Unemployment Insurance Matters
 Manage Payments                                               View Transaction History                          Only Benefit/Claim Related Matters
 Payment View Only                                             Benefit/Claim Information                         Only Tax Related Matters

Employer Authorized Signature                                                                                    Date

Printed Name                                                                                       Title         Phone
                                                                                              Online Submission: www.myiowaui.org 
Complete and sign this form to be valid.                                               Email Completed Form: iwduitax@iwd.iowa.gov        
                                                                                         Mail Completed Form: Iowa Workforce Development 
                                                                                                            Unemployment Insurance Tax Bureau 
                                                                                                            1000 E Grand Ave 
Equal Opportunity Employer/Program                                                                          Des Moines Iowa  50319-0209 
Auxiliary aids & services are available upon request to individuals with disabilities. 
For deaf and hard of hearing, use Relay 711.                                                                Questions: 888-848-7442 

Declaration of Power of Attorney or Authorized Representative 
68-0092 (07-16) 

                                                    Instructions 
  
Power of Attorney or Authorized Representation may be assigned online at:  www.myiowaui.org

Iowa Workforce Development (IWD) will only discuss            Who Must Sign the Declaration? 
confidential Unemployment Insurance (UI) information with       1. Sole Proprietor 
authorized parties. An employer must have a signed                Must be signed by individual owner 
Declaration of Power of Attorney or Authorized                  2. Corporation or Association 
Representative (herein after called Declaration) on file with     Must be signed by an officer of the corporation or 
IWD.                                                              association having authority to legally bind the 
                                                                  corporation or association. The corporation or 
Purpose of Declaration                                            association must certify that the officer has such 
A Declaration is a legal document authorizing someone else        authority. 
to act on an employer's behalf.                                 3. Trust or Conservator 
                                                                  Must be signed by fiduciary authority 
                                                                4. Partnership 
Who Can Be Declared a Power of Attorney or                        Must be signed by all partners, or if executed in the 
Authorized Representative?                                        name of the partnership, by the partner or partners 
  ·Attorney                                                       duly authorized to act for the partnership, who must 
  ·Accountant, Firm                                               certify that the partner(s) has such authority. 
  ·Tax preparer or                                              5. Limited Liability Corporation 
  ·Any individual acting on behalf of an employer.                Must be signed by a member of the LLC 
                                                                
Privileges of Both Power of Attorney and Authorized           Duration of Authority, Canceling or Withdrawing a 
Rep                                                           Declaration 
Both are allowed to perform one or more of the following on   The Declaration will remain in effect until revoked. The 
behalf of any employer:                                       employer can do this by logging into their account on www.
  ·Sign and file reports for UI matters 
                                                              myiowaui.org, select assign agent option, select the agent 
  ·Make deposits and payments for UI 
  ·Receive UI information, notices and other                  you want to revoke and enter an end date.  The employer, 
    communication regarding authorization granted             Power of Attorney, or Authorized Representative  can also 
  ·Access electronic records specific to the employer         revoke the Declaration by notifying IWD in writing.  
  ·Represent the employer in any formal or informal 
    meeting, hearing, decision or appeal, final or            Submitting a New Declaration 
    otherwise.                                                A new Declaration revokes a prior Declaration for the 
                                                              specified transactions. The Declaration becomes effective 
Additional Privileges for Power of Attorney Only              the date it is received by IWD. 
The Authorized Representative cannot be granted the             
following privileges:                                         Submission Options: 
  ·Enter into any compromise with IWD                           
  ·Execute any release from liability required by IWD as            · Online: www.myiowaui.org - Log into account,   
    a prerequisite to divulge otherwise confidential                      select assign agent option, enter agent R number,  
    information concerning the employer                                   assign roles 
  ·Other acts as expressly stipulated in writing by the         
    employer                                                    · Email completed form:  
                                                                       IWDUITAX@IWD.IOWA.GOV 
  
Assign Agent Roles                                              · Mail completed form:   Iowa Workforce  Development 
As the true and lawful agent, you are able to represent the                             UI Tax Bureau  
employer in all roles or only the specific roles selected in                            1000 E Grand Ave 
this section.  See page 2 for description of roles.                                           Des Moines IA 50319-0209

  Note:  Address change requests must be received in writing by IWD if form 68-0092 is submitted by email or mail.            

Declaration of Power of Attorney or Authorized Representative 
68-0092 (07-16) 

                                     Instructions

Agent Roles

MyIowaUI Website Roles               Description
All Roles                            All functions
System Administrator                 Assign Agent 
                                     Update Users
Maintain Account                     Update Name 
                                     Update Address 
                                     Update Officer/Member/Partner 
                                     Update Reporting Units 
                                     Update Banking Information 
                                     Update Accountant 
                                     Cancel an Election of Coverage 
                                     Elect Coverage for Non-Covered Employees 
                                     Request Contributory/Reimbursable Change 
                                     Report Bankruptcy Information 
                                     Inactivate Account/Reactivate Account 
                                     Change Owner
Manage Payment                       Make Payment 
                                     Request a Payment Plan 
                                     Request Waiver of Penalty, Interest & Fees 
                                     Credit and Debit 
                                     View Payment History 
                                     Request Refund
Payment View Only                    View Payment History - Cannot make changes
Submit / Change Wage Detail          Submit Wage Report 
                                     Submit Wage Adjustment 
                                     View Submission Summary 
                                     View Wage Detail   
                                     Labor Market Information 
                                     Request IRS Certification

Wage Detail View Only                View Quarterly Report Summary - Cannot make changes 
                                     View Wage Detail - Cannot make changes
View Correspondence                  View Only - Cannot make changes
View Transaction History             View Only - Cannot make changes
Benefit/Claim Information            View Benefit / Claim Information for Reporting Unit

Authorized Communication 
                                     Desciption
Roles
All Unemployment Insurance Matters   Communicate with unemployment insurance staff regarding 
                                     benefit / claim and tax related matters
Only Benefit / Claim Related Matters Communicate with unemployment insurance staff regarding 
                                     benefit / claim matters only
Only Tax Related Matters             Communicate with unemployment insurance staff regarding tax 
                                     related matters only