OHIO DEPARTMENT OF JOB AND FAMILY SERVICES 
  P.O. Box 182404
  Columbus, Ohio 43218-2404
  (614) 466-2319
  http://unemployment.ohio.gov 
                                                                                                                        FOR 0006A

  AGENT AUTHORIZATION FORM

  To immediately authorize an agent (third party administrator, accountant, payroll company, etc) to act on your behalf regarding your 
  account, please visit http://unemployment.ohio.gov. If you prefer, you may submit your information by completing this form and your 
  account will be updated within 2-3 weeks. When completing this form, please print, using block capital letters in black ink.  For example: 

  Section I - Employer and Representative Information  

   Employer Legal Name 

   Employer ID                              Plant Number (If none, please leave blank.)

   Employer Phone Number 

                 -             -

   Agent Name 

   Agent ID                                                                                         Agent Phone Number 

                                                                                                               -       -

   Agent Address Line 1 - Enter street address or P.O. box information here (for example, 123 Main St., P.O. Box 123.)

   Agent Address Line 2 - Enter secondary address information here (for example, STE 123, APT A, 1st FL. If none, please leave blank.)

   City 

   State              ZIP                                                                             Country  
                                           -

   Province - International addresses only                                                                        Postal Delivery Code – International addresses only 

  JFS 20106 (Rev. 12/2022)                                                                                                                                    
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  Section II - Assign Roles and Responsibilities

  To give a new agent access to your account, check the role(s) you want the agent to have and enter the "Access Begin Date" (must be the 
  beginning of a quarter for "Wage Submission") and "Access End Date" (optional) for the selected roles. 
    
  For all roles except "Wage Submission," once an end date is entered, the agent will no longer have access to those roles after the "Access End 
  Date" provided. If no end date is entered, the access will continue indefinitely. 
    
  For "Wage Submission," the dates of access will allow the agent to update your wage records for all quarters within the access dates, 
  regardless of the current date. For example, if you give an agent access for the first quarter of the year, the agent will be able to access the 
  wage records for that quarter at any time. If you wish to completely remove access for the agent, which would prevent them from accessing 
  quarters they were previously authorized for, select the "Remove Access" box for the agent. 
    
  You cannot grant two agents access to the same role during the same time period. If you want to change agents, you must remove the role 
  from the existing agent by entering an "Access End Date."

  1a.  To what role does the authorization or dissolution  1b.   For the roles selected in question 1a, provide "Access Begin Date" 
    selected in Section II apply?                                  and "Access End Date" (Optional)
         (Please check all that apply.)

       Wage Submission                                                        Access Begin Date
                                                                                    /                / 
       Payment Submission
                                                                              Access End Date
       Account Maintenance Updates
                                                                                    /                / 

       Appeals                                                                Remove Access

       Tax Rates

  Section III - Signature
  I hereby acknowledge that by signing this document I relieve the Ohio Department of Job and Family Services from any liability 
  arising from the exercise of rights and causes of action on account of or growing out of failure of the undersigned to receive any 
  correspondence sent to the representative indicated in Section III, including, but not limited to: 
                                       1. Notification required by Section 4141.26; 
                                       2. Injury caused by untimely appeal.  
  This authorization, voluntarily given by the undersigned, shall remain in full force and effect until such time as the agency is notified 
  in writing by the undersigned or by the designated representative that the relationship has been dissolved.  

  Employer Signature 
  NOTE: Must be owner, partner, member, or corporate officer            Title:

                                                           Date: 

                                                                              /              / 

  JFS 20106 (Rev. 12/2022)                                                                                                             
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