LIMITED POWER OF ATTORNEY 
 
KNOW ALL PERSONS BY THESE PRESENTS: 
 
THAT, ________________________________, GA DOL Account No. _________________, 
having its principal office at ______________________________________________________ 
hereby appoints ______________________________ as its true and lawful agent with authority 
to represent the said _______________________ before the Georgia Department of Labor, 
until further notice, in connection with all matters affecting State Unemployment Insurance 
Taxes including, with limitation, tax contributions and experience ratings, but excluding claims. 
 
This Power of Attorney supersedes and revokes any prior power of attorney authorization from 
the named employer relating to the subject matter hereof.  The undersigned warrants that he or 
she is authorized to execute this Power of Attorney. 
 
The legal mailing address of the named employer shall remain the same.  The employer will 
continue to receive all correspondence pertaining to contributions, claims and experience 
ratings. 
 
IN WITNESS WHEREOF, the undersigned has duly executed and delivered this Power of 
Attorney on behalf of the named employer this _______ day of ___________________, 20___. 
 
                                                     ___________________________________ 
                                                     Employer’s Name 
                                                                                                   
         By: ___________________________________ 
                                                     Signature 
                                                                                                   
                                                     ___________________________________ 
                                                     Print or Type Name 
                                                                                                   
                                                     ___________________________________ 
                                                     Title