Arizona Limited Power of Attorney Form

LIMITED POWER OF ATTORNEY
The Limited Power of Attorney form is used by employers to authorize a third party to represent them before the Arizona Department
of Economic Security (DES) in the Unemployment Insurance (UI) matters specified on the form. Such authorization also permits DES
to provide the representative with any confidential information concerning the employer’s Arizona UI account that is related to those
matters.
Specify which matters the authorization applies to by checking the appropriate checkbox(es) on the form. If you want the
authorization limited to a specific matter, such as a specific DES decision under appeal, check the “Other, specific UI matter”
checkbox and briefly describe the matter in the space below to identify it specifically. Provide the representative’s address
immediately below that if you want to have all correspondence related to the “Other, specific UI matter” mailed to that address.
If you want to change the primary mailing address for general DES correspondence related to the employer’s UI account, complete the
area of the form provided for that purpose. You may also specify a separate mailing address for unemployment benefit claim-related
notices by completing the area of the form provided for that purpose. Such a separate address is sometimes advisable, to enable the
timely protesting of claims. Protests must be returned or postmarked within 10 business days after the date on the claim filing notice
(Notice to Employer – UB-110) to be considered timely.
Submit the completed form with the original signature of a duly qualified officer or owner of the employer’s business to the UI Tax
Employer Registration Unit at the address below. Questions about the use or completion of the form should also be directed to the
Employer Registration Unit.
ADES - UI Tax Section – 911B
Employer Registration Unit
P.O. Box 6028
Phoenix, Arizona 85005-6028
Telephone – (602) 771-6602
Fax – (602) 532-5539
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans
with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II
of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs,
services, activities or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The
Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity.
Auxiliary aids and services are available upon request to individuals with disabilities. For example, this means if necessary, the
Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print
materials. It also means that the Department will take any other reasonable action that allows you to take part in and
understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to
understand or take part in a program or activity because of your disability, please let us know of your disability needs in
advance if at all possible. To request this document in alternative format or for further information about this policy, contact the UI
Tax office at 602-771-6606; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available
upon request.• Ayuda gratuita con traducciones relacionadas a los servicios del DES está disponible a solicitud del cliente.
POA
UIT-1146A FORFF (9-13)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration • Tax Section
P.O. BOX 6028, Phoenix, AZ 85005-6028
LIMITED POWER OF ATTORNEY
EMPLOYER’S NAME
ARIZONA UI ACCOUNT NO. OR FEDERAL EIN
hereby appoints
(Representative Company’s Name)
(Representative Company’s Phone No.)
to represent said employer before the Arizona Department of Economic Security (DES) in all matters related to Arizona
Unemployment Insurance (UI) specified below until further notice (check all boxes that apply):
UI tax preparation/filing including filing/paying via the Internet Tax and Wage System (TWS)
All other general UI matters (all benefit claim protests, all appeals of agency determinations, etc.)
Other, specific UI matter (provide details below to identify the matter or no action will be taken):
Provide representative’s address if you want mail concerning the “Other, specific UI matter” sent there:
REPRESENTATIVES COMPANY’S ADDRESS (P.O. Box/Street No., Street, City, State, ZIP)
COMPLETE THIS AREA ONLY IF YOU WANT TO CHANGE THE EMPLOYER’S PRIMARY MAILING ADDRESS*
EMPLOYER’S NAME
PHONE NO.
ADDRESS (P.O. Box/Street No., Street, City, State, ZIP)
*All general UI correspondence including liability determinations, tax and wage report forms, tax assessments, and notices of tax
rates, benefit charges, appeals, liens and claim filings are mailed to the PRIMARY address. If you want a SEPARATE mailing
address for notices of unemployment benefit claim filings, claim determinations and claim appeals, complete the address area below.
OPTIONAL SEPARATE MAILING ADDRESS FOR UNEMPLOYMENT BENEFIT CLAIM-RELATED NOTICES
EMPLOYER’S NAME
PHONE NO.
ADDRESS (P.O. Box/Street No., Street, City, State, ZIP)
In witness whereof, said employer has caused this instrument to be attested by the signature of a duly qualified officer or owner this
day of
,
.
(Day)
(Month)
(Year)
This Limited Power of Attorney authorization cancels and/or supersedes all prior authorizations related to the specified matters and
remains in effect until revoked in writing by either the employer or the representative.
PRINT NAME (First, M.I., Last)
TITLE
SIGNATURE
FOR AGENCY’S USE ONLY
REVISED PRIMARY ADDRESS
REVISED/ADDED CLAIMS ADDRESS
INITIALS
DATE
NOTES