NORTH CAROLINA DEPARTMENT OF COMMERCE 
                   DIVISION OF EMPLOYMENT SECURITY 
                   Instructions for Completion of Power of Attorney Forms 
 
POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE 
 
Use this form for the representative to file Employer’s Quarterly Tax and Wage Reports, to file  
benefit information, and to generally authorize the reporting agent to do those things that the 
employer may do concerning the employer’s tax and claims records with the DES. In item 9, 
strike out (is) or (is not) as appropriate. If no selection is made, the address will not be changed. 
 
Note 
Neither form complies with the requirements of N.C.G.S. 96-17(b) to allow an individual under the 
supervision of an attorney licensed to practice law in the State of North Carolina to represent 
employers in hearings and to enter appeals. For an individual to represent an employer under the 
supervision of an attorney pursuant to the provision of N.C.G.S. 96-17 (b), please complete 
Notice of Attorney 
 
Supervision..REVISED 01/2012