MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

                       POWER OF ATTORNEY

I. Business/Taxpayer
Name

Address                                                     City                     State                           ZIP Code

Phone Number                                                FEIN                     UI Tax Number

II. Does Hereby Appoint
Name of Appointed Representative                                                     Phone Number

Address                                                     City                     State                           ZIP Code

as attorney(s)-in-fact to represent taxpayer before the Missouri Division of Employment Security with respect to the following
Unemployment Insurance matter(s):
Type of Representation (check one):  UI Tax and Claim Matters      UI Tax Only    UI Claim Only

Change employer’s official mailing address to that of appointed representative for (check all that apply):
                                  UI Tax Matters                 UI Claim Matters

          This authorization supersedes and revokes any prior power of attorney or authorization on file with the
                       Missouri Division of Employment Security relating to the subject matter hereof.
               The authorization does not apply to the Division of Employment Security appeals process.

III. Signature of Business Representative/Taxpayer
Name (printed)                                              Title

Signature                                                                            Date

IV. Signature of Appointed Representative
Name (printed)                                              Title

Signature                                                                            Date

V. Mail or fax completed form to: Missouri Division of Employment Security
                                    Attn: Liability Unit
                                    P.O. Box 59
                                    Jefferson City, MO 65104-0059
                                    Fax Number: 573-751-7483

IMPORTANT: If needed, call 573-751-3340 for assistance in the translation and understanding of the information in this document.
¡IMPORTANTE!: Si es necesario, llame al 573-751-3340 para asistencia en la traducción y entendimiento de la información en este documento.
          Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services
               are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
                                                                                                          MODES-4444 (05-16) AI
                                                                                                                                Cont.