ALASKA DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT 
                  Division of Employment and Training Services – Unemployment Insurance (UI) Tax 
                                       P.O. Box 115509, Juneau, AK 99811-5509 
                          (888) 448-3527 or (907) 465-2757, Alaska Relay: (800) 770-8973, 
                           Fax: (907) 465-2374  orEmail:  esd.tax@alaska.gov  
                                                         
                                        POWER OF ATTORNEY 
                                                         
KNOW ALL MEN BY THESE PRESENTS: 
    That                                                                       UI account no.                     
                                       (business name) 
 
Federal ID no.                               does hereby constitute and appoint 
                           ________________________________________________________________  
                                                          (designated authority) 
                           ________________________________________________________________  
                                                       (designated authority mailing address) 
                           ________________________________________________________________  
                                       City               State                               Zip code 
                           ________________________________________________________________  
                                            Phone                             Fax 
its true and lawful attorney in fact with full power and authority to represent said company before the Alaska 
Department of Labor and Workforce Development, Division of Employment and Training Services effective 
immediately and until this authority has been revoked in writing in connection with any and all Unemployment 
Insurance matters as indicated below. For areas you would like this Power of Attorney to apply, check either “New” 
or “Add.” “New” will supersede previous Powers of Attorney for lines checked. “Add” does not supersede previous 
Powers of Attorney for lines checked. 
New  Add 
         1. Filing of completed forms, including claims for refund or adjustment of account, liability or status 
              determinations and wage record reports 
         2. Receipt of Tax Rate Notices (TR02) 
         3. Payment of contributions and any penalties and interest assessed on the account 
         4. Discuss matters affecting the experience record and contribution rate of the employer account 
         5. Discuss all matters affecting any adjustments to the employer’s account 
         6. Enroll in the State Information Data Exchange System (SIDES) for electronic: 
                Notification of Separation information       Wage Earnings Audits 
         Contact name:                                                        Phone:                              
         Email:                                                  
         7. All matters and forms affecting UI benefits, job separation information, hearing notices and decisions 
         8. Allow discussion of rates and designated authority (above) supplemental reports/payments. 

   IN WITNESS WHEREOF, the said                                                                                   
                                                          (owner, officer or member) 
has caused this instrument to be duly attested by the signature of its duly qualified officer this       day of  
                         , 20____. 
By (employer signature):               Printed name                           Title and company: 
 
STATE: _______________ COUNTY OF______________________________, __________________, 20______ 
  Then, personally appeared the above named____________________________________________ whose 
title is____________________________________ and acknowledged the foregoing instrument to be his/her free 
act and deed in his/her said capacity. 

Notary public                          Type or print name                     My commission expires 

                                                                                                         Rev. 5/19