MISSOURIDEPARTMENTOFLABORANDINDUSTRIALRELATIONS

                     POWEROFATTORNEY

I. Business/Taxpayer
Name

Address                                         City                           State                       ZIPCode

PhoneNumber                                     FEIN                           UITaxNumber

II. DoesHerebyAppoint
NameofAppointedRepresentative(BusinessName)     FEIN                           PhoneNumber

Address                                         City                           State                       ZIPCode

asattorney(s)-in-facttorepresenttaxpayerbeforetheMissouriDivisionofEmploymentSecuritywithrespecttothefollowing
UnemploymentInsurancematter(s):
Changeemployer'sofficialmailingaddresstothatofappointedrepresentativefor(checkallthatapply):
c UITaxMatters                 c UIClaimMatters                  c InformationOnly(Addressremainsemployers)
          Thisauthorization supersedesandrevokesanypriorpowerofattorneyorauthorizationonfilewiththe
                    MissouriDivisionofEmploymentSecurityrelatingtothesubjectmatterhereof.
               Ifthebusiness/taxpayerhasmultiplePowerofAttorneyspleasecheck: c MultiplePOA's
               TheauthorizationdoesnotapplytotheDivisionofEmploymentSecurityappealsprocess.
III. SignatureofBusinessRepresentative/Taxpayer
Name(printed)                                   Title

Signature                                                                      Date

IV. SignatureofAppointedRepresentative
Name (printed)                                  Title

Signature                                                                      Date

V. Mailorfaxcompletedformto:          MissouriDivisionofEmploymentSecurity
                                               Attn:LiabilityUnit
                                               P.O.Box59
                                      JeffersonCity,MO65104-0059
                                      FaxNumber:573-751-7483

              AppointedRepresentativesMUSTberegisteredasathirdpartytoaccessclientinformationonline.
                    Forfurtherdetailscall573-751-3340orregisteronlineatuinteract.labor.mo.gov.

IMPORTANT:Ifneeded,call573-751-3340forassistanceinthetranslationandunderstandingoftheinformationinthisdocument.
¡IMPORTANTE!:Siesnecesario,llameal573-751-3340paraasistenciaenlatraducciónyentendimientodelainformaciónenestedocumento.
          MissouriDivisionofEmploymentSecurityisanequalopportunityemployer/program.Auxiliaryaidsandservices
               areavailableuponrequesttoindividualswithdisabilities. TDD/TTY:800-735-2966 RelayMissouri:711
                                                                                              MODES-4444(05-19)AI
                                                                                                               UITax