SDEformE2108v3-FormPOA

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

POWER OF ATTORNEY (POA)/AUTHORIZATION OF AGENT

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

Effective Date:

Required, please provide the effective date

That the Undersigned Employer:

Employer Name is required.

Employer's Mailing Address:

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

(Check One)

Please select an option before printing.

Coporation

Partnership

Individual

LLC

Federal ID Number:

FEIN is required.

SD RA Account Number:

Applied For

Does Hereby Appoint POA:

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:

POWER OF ATTORNEY/ADDRESS AUTHORIZATION (Mark all that apply)

TAX Power of Attorney

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.

BENEFITS Power of Attorney

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.

LIMITED Power of Attorney

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.

Signature:

Date:

Employer's Name and Title:

You must type the empoyer name before printing.

Telephone Number:

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