PRINT      CLEAR
           NC Dept. of Commerce 
           Division of Employment Security 
           Post Office Box 26504, Raleigh, NC 27611-6504         (* All fields are required unless specified optional *)

                             POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE 

           Part 1.  Employer’s Information. Must sign and date this form on page 2 

           EMPLOYER 'SNAME AND ADDRESS                                                      STATE UNEMPLOYMENT TAX ACCOUNT NUMBER 
            (Exactly as shown on the Division of Employment Security Records) 

                                                                                            FEDERAL EMPLOYER IDENTIFICATION NUMBER 
                                                                                                   - 

Part 2.   Representative 
REPRESENTATIVE NAME                                                                         PHONE NUMBER 

ADDRESS                                                                                     CITY, STATE, ZIPCODE 

           EMAIL ADDRESS                                                                    FAX NUMBER 

           The above representative is appointed to represent the above-referenced employer in any of the matters pertaining 
           to contributions (tax) and benefits (claims) as listed below. An agent appointed pursuant to this Power of Attorney 
           and Declaration may: 

            1. Complete and submit documents for filing employer’s tax and wage reports;
            2. Complete and submit documents regarding an employer’s tax rate, contributions, and direct reimbursements;
            3. Respond to benefit claims documents, including responding to requests for information about a
            claimant’s separation or status;
            4.Engage in discussion with a representative of the Division of Employment Security regarding the actions                   listed
            above;and
            5.Accept or receive correspondence sent by DES regarding claims for benefits or an employer’s                    contributions.
                The undersigned employer acknowledges that the agent appointed pursuant to this Power of Attorney
                and  Declaration  of  Representative  is  not  authorized  to:  (a)  Represent  the  employer  in  hearings  (b)
                Enter  appeals  except  as  authorized  by  N.C.  Gen.  Stat.  §  96-17(b),  and  04  N.C.  Admin.  Code
                24A.0110(a) and (b).

                The undersigned employer further acknowledges that its mailing address for tax matters will remain
                unchanged,  unless  the  employer  submits  a  change  of  address  in  accordance  with  04  N.C.  Admin.
                Code 24A.0102.

           Part 3.  Agent    AccountNumber 

           Your representative may request an Agent account number with this Division to perform above services on behalf of your 
           business. If your representative has a n Agent accountnumber, please provide this number below. If not, visit the Division’s 
           website at www.des.nc.gov/employers and click on ‘Third-Party Administrators and Agents' for more information. 

(optional) Agent account number: 

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Part 4.  Declaration of Representative 

This Power of Attorney and Declaration of Representative shall become effective on
and shall remain in effect until revoked by the employer, the representative, or the Division of 
Employment Security. On the effective date, this Power of Attorney and Declaration of Representative 
revokes any earlier power of attorney on file with the Division of Employment Security. 

                                              (SEAL) 

AUTHORIZING SIGNATURE 
(Individual signing must be the proprietor, a general partner or duly elected corporate official exactly as shown on the Division of 
Employment Security records). 

TYPED OR PRINTED NAME                                              TITLE

SIGNED AND SWORN to before me on this      day of                  . 

E-NOTARY PUBLIC SEAL

REPRESENTATIVE SIGNATURE 

TYPED OR PRINTED NAME                                              TITLE

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