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 or Email: 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immediately and until this authority has been revoked in writing in connection with any and all Unemployment 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

               If #6 or #7 are checked (New or Add), email this form to jnu.uitech@alaska.gov

         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. 7/24