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SD EForm - 2108 V3    Complete and use the button at the end to print for mailing. To print a blank form, use print options provided by your browser

Form POA


South Dakota Department of Labor and Regulation
Reemployment Assistance
PO Box 4730
Aberdeen, SD 57402-4730
Phone 605.626.2312 • Fax 605.626.3347

Required, please provide the effective date

Employer Name is required.

Address (PO Box/Street) is required

City is required

State is required

Invalid Zip Code: Make sure the zip code is in the standard US or Canadian format

Please select an option before printing.

FEIN is required.


Contact Name is required.

Along with its divisions and subsidiaries the true and lawful attorneys-in-fact of the undersigned, until further written notice, to represent the undersigned before any and all government bodies, agencies or instrumentalities, regarding the following matters:


Indicate below the address that should receive all Tax information including rate notices, quarterly reports, benefit charges, delinquent notices, debit/credit notices. If left blank, the address will default to the employer’s mailing address listed above.

Indicate below the address that should receive all Benefit information, including claim notices and appeals. If left blank, the address will default to the employer’s mailing address listed above.

Indicating Limited Power of Attorney denotes that the appointed POA listed above files the quarterly reports for the employer. Limited Power of Attorney also allows access to employer payroll information and tax rates. There is no address change with Limited Power of Attorney.

Each of said attorneys-in-fact shall have the power to act with or without the others and the power and authority to perform, in the name of and on behalf of the undersigned, every act necessary to carry out the subject matter hereof as fully as the undersigned could do. The undersigned hereby ratifies and approves the acts of said attorneys-in-fact. This authorization supersedes and revokes any prior power of attorney or authorization from the undersigned relating to the subject matter hereof.

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Invalid Phone Number, format number as: 605-555-1234