Government of the District of Columbia 
Department of Employment Service 
Office of Unemployment Compensation – Tax Division 
4058 Minnesota, Avenue, N.E. 
WASHINGTON, DC 20019 
Phone: (202) 698-7550   
Email: uitax.info@dc.gov 
                                                             POWER OF ATTORNEY 

Name of Legal Entity:  _____________________________________________________   Trade Name:  _______________________ 

Federal ID Number:  _____________ SUI Number:  __________ 

I, _______________________________________________________________________________________________________ am 
            Name and Personal Mailing Address of Owner, Officer, or Duly Authorized Representative – Do Not List PO Box 
 the owner          an officer or       a duly authorized representative of 

___________________________________________________________________________________________________________, 
                                                         Name and the Location of the Business 
and I appoint ________________________________________________________________________________________________ 
                                                                                      Name and Address of the TPA Appointed 
as my agent (attorney-in-fact) to act for me on behalf of the above-named business in any lawful way with respect to the following initialed subjects 
with the District of Columbia Department of Employment Services.   
PLACE YOUR INITIALS BY THE FUNCTIONS AUTHORIZED THROUGH THE POWER OF ATTORNEY: 
________ (1) Unemployment Insurance Benefit Claims and Litigation. 
                         The timely processing of unemployment benefit claims: 
                         (a) Employee separation and wage requests 
                         (b) Benefit appeals; employer charge protests 
________ (2) Tax matters. 
                         (a) Employer registrations; account updates 
                         (b) Filing and payment of taxes related to employer liability to the District of Columbia 
                         (c) Tax appeals 

THIS POWER OF ATTORNEY IS EFECTIVE BEGINNING ____________ AND WILL EXPIRE ON ______________. 
                                                                                        MM/DD/YYYY                                            MM/DD/YYYY 
I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third 
party until the third party learns of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of 
reliance on this power of attorney. Further, I agree that the power of attorney does not relieve my responsibilities outlined in Title 51 of the District of 
Columbia Code. 

Signed this ________ day of ______________, ________                                       _____________________________________________ 
              Day                                       Month                 Year                    Signature (Employer) 

Declaration of Representative: Representative(s) must complete this section and sign below. 

Under penalties of perjury, I declare that: 
           I am not currently under suspension or disbarment from practice before the Internal Revenue Service (IRS).
           I am aware of regulations contained in Treasury Department Circular #230, as amended, concerning the practice of attorneys, certified
            public  accountants,  enrolled  agents,  enrolled  actuaries,  and others  and the penalties  for  false  or fraudulent  statements  provided  in  DC
            Official Code 47-4106.
           I am authorized to represent in the District of Columbia the taxpayer(s) identified for the tax matter(s) specified herein; and I am one of the
            following:
            (a)          A member in good standing of the bar of the highest court of the jurisdiction shown below. 
            (b)          A Certified Public Accountant duly qualified to practice in the jurisdiction shown below. 
            (c)          An Enrolled Agent under the requirements of the Treasury Department Circular # 230. 
            (d)          A bona fide officer of the taxpayer’s organization. 
            (e)          A full-time employee of the taxpayer, trust, receivership, guardian or estate. 
            (f)          A member of the taxpayer’s immediate family (i.e. spouse, parent, child, brother, or sister). 
            (g)          An  actuary  enrolled  by  the  Joint  Board  for  the  Enrollment  of  Actuaries  (the  authority  to  practice  before  IRS  is  limited  by 
                         Treasury Department Circular #230). 
            (h)          An unenrolled return preparer under the requirements of Treasury Department Circular #230. 
            (i)          A general partner of a partnership. 
            (j)          Other.  
Designation – Inset above letter (a-j)             Jurisdiction (state)                              Signature                                           Date 

Form No.: OUCTAX-1