UIT-1146A FORFF (4-18) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
                                          Employer Engagement Administration

                       LIMITED POWER OF ATTORNEY

The Limited Power of Attorney form is used by employers to authorize a third party to represent them before the Arizona 
Department of Economic Security (DES) in the Unemployment Insurance (UI) matters specified on the form. Such 
authorization also permits DES to provide the representative with any confidential information concerning the employer’s 
Arizona UI account that is related to those matters.

Specify which matters the authorization applies to by checking the appropriate checkbox(es) on the form. If you want 
the authorization limited to a specific matter, such as a specific DES decision under appeal, check the “Other, specific UI 
matter” checkbox and briefly describe the matter in the space below to identify it specifically. Provide the representative’s 
address immediately below that if you want to have all correspondence related to the “Other, specific UI matter” mailed to 
that address.

If you want to change the primary mailing address for general DES correspondence related to the employer’s UI account, 
complete the area of the form provided for that purpose. You may also specify a separate mailing address for unemployment 
benefit claim-related notices by completing the area of the form provided for that purpose. Such a separate address is 
sometimes advisable, to enable the timely protesting of claims. Protests must be returned or postmarked within 10 business 
days after the date on the claim filing notice (Notice to Employer – UB-110) to be considered timely.

Submit the completed form with the original signature of a duly qualified officer or owner of the employer’s business to the 
UI Tax Employer Registration Unit at the address below. Questions about the use or completion of the form should also be 
directed to the Employer Registration Unit.

                                           ADES - UI Tax Section 
                                           Employer Registration Unit
                                           P.O. Box 6028 - Mail Drop 5881
                                           Phoenix, Arizona 85005-6028 
                                           Telephone – (602) 771-6602 
                                           Fax – (602) 532-5539
                                           Email – UITStatusClerical@azdes.gov

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the 
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in 
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, 
genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take 
part in a program, service, or activity.  Auxiliary aids and services are available upon request to individuals with disabilities.  
To request this document in alternative format or for further information about this policy, Contact the UI Tax Office at 602-
771-6606; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible
en español en línea o en la oficina local.

UIT-1146A FORFF (4-18)          ARIZONA DEPARTMENT OF ECONOMIC SECURITY 
                                         Employer Engagement Administration
                                P.O. BOX 6028, Mail Drop 5881, Phoenix, AZ 85005-6028

                                LIMITED POWER OF ATTORNEY
EMPLOYER INFORMATION
EMPLOYER NAME                                                       ARIZONA UI ACCOUNT NO. OR FEDERAL EIN

Hereby appoints 

(Representative Company’s Name)                                     (Representative Company’s Phone No.)
To represent said employer before the Arizona Department of Economic Security (DES) in all matters related to Arizona 
Unemployment Insurance (UI) specified below until further notice (check all boxes that apply):
                 UI tax preparation/filing including filing/paying via the Internet Tax and Wage System (TWS)
                 All other general UI matters (all benefit claim protests, all appeals of agency determinations, etc.)
                 Other, specific UI matter (provide details below to identify the matter or no action will be taken):

Provide representative’s address if you want mail concerning the “Other, specific UI matter” sent there:
REPRESENTATIVES COMPANY’S ADDRESS (P.O. Box/Street No., Street, City, State, ZIP) 

COMPLETE THIS AREA ONLY IF YOU WANT TO CHANGE THE EMPLOYER’S PRIMARY MAILING ADDRESS
EMPLOYER NAME                                                       PHONE NO.

ADDRESS (P.O./Street No. Street, City, State, ZIP) 

*All general UI correspondence including liability determinations, tax and wage report forms, tax assessments, and notices of tax rates,
benefit charges, appeals, liens and claim filings are mailed to the PRIMARY address. If you want a SEPARATE mailing address for
notices of unemployment benefit claim filings, claim determinations and claim appeals, complete the address area below.
OPTIONAL SEPARATE MAILING ADDRESS FOR UNEMPLOYMENT BENEFIT CLAIM-RELATED NOTICES
EMPLOYER NAME                                                       PHONE NO.

ADDRESS (P.O./Street No. Street, City, State, ZIP) 

In witness whereof, said employer has caused this instrument to be attested by the signature of a duly qualified officer or owner this day of 
 (Day)                           (Month)                             (Year)                       .

This Limited Power of Attorney authorization cancels and/or supersedes all prior authorizations related to the specified matters and 
remains in effect until revoked in writing by either the employer or the representative
PRINT NAME (First, M.I, Last)                                       TITLE

SIGNATURE 

FOR AGENCY USE ONLY

 REVISED PRIMARY ADDRESS        REVISED/ADDED CLAIMS ADDRESS
INITIALS                  DATE            NOTES