Reset Form                                    Ohio Department of Job and Family Services 
                                      EMPLOYER'S REPRESENTATIVE AUTHORIZATION 
 
P.O. BOX 182059 
Columbus, OH 43215-2059 
(614) 466-4047 
EMPCHRG@jfs.ohio.gov 
 
Section I - Benefits Authorization for Representation or Dissolution of Representation 
    I hereby authorize the Ohio Department of Job and Family                                I am hereby notifying the Ohio Department of Job and Family 
 Services to allow the representative named in Section II to act                     Services that I wish to dissolve my relationship with the 
 on my behalf for all matters pertaining to the service functions(s)                 representative named in Section II. The Ohio Department of Job 
 identified in Section III.                                                          and Family Services should no longer allow the representative 
                                                                                     named in Section II to act on my behalf for matters pertaining to the 
 NOTE: If correspondence should be sent on a regular basis to                        service function(s) identified in Section III or send them any 
 the representative, please choose representative for question                       information pertaining to my account. 
 #1.b in Section III. 
 
Section II - Employer and Representative Information 
  When completing this form, please print using block capital letters in black ink. For example:  
                                                                                                    ABCD E F GHI
  Employer Name 
                                                                                                                                                     
 Employer Address 
                                                                                                                                                     
 City 
                                                                                                                                                     
  State Zip                                                                       Country 
                                           -                                                                                  
  Employer Account Number                                                           FEIN 
                                       -           -                                                                           
 Employer Phone Number 
                -                      -                    
  Representative or Third Party Administrator Name 
                                                                                                                                                             
  Representative or Third Party Administrator Number                         Representative or Third Party Administrator Phone Number 
                                                                                             -                -                           

  Representative Address Line 1 
                                                                                                                                                             
  Representative Address Line 2 - Please enter P.O. Box here 
                                                                                                                                                             
 City 
                                                                                                                                                             
  State Zip                                                                       Country 
                                                                              
                                           -                                                                                                                 
  Province - International addresses only                                           Postal Delivery Code - International addresses only 
                                                                                                                                           
JFS 00501 (Rev. 10/2010)                                                                                                                            Page 1 of 2 

Section III - Service Function and Correspondence 
 
  1.a  To what service function(s) does the authorization or                1.b  For the service function(s) selected in question #1 a, where 
     dissolution selected in Section II apply?                                 should the correspondence be sent on a regular basis? 
     (Please check all that apply)                                             (Choose only one) 
 
      Monthly Benefit Charge Statement                                         Employer               Representative or Third Party Administrator 
 
      Request for Information                                                  Employer               Representative or Third Party Administrator 
 
      Request for Separation Information                  Interface            Employer               Representative or Third Party Administrator 
 
     Determinations                                                            Employer               Representative or Third Party Administrator 
 
     Appeals                                                                   Employer               Representative or Third Party Administrator 
 
      Employer Third Party Administrator                                       Employer               Representative or Third Party Administrator 
 
Section IV - 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 as 
 indicated in Section III, including but not limited to: 
 
     1. Notification required by Section 4141.26 
     2. Injury cased 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 
                                                               
                                                                           /                   /                                               
 
 Employer Name 
                                                                                                                                      
 Employer Phone Number 
             -                       -             
 
JFS 00501 (Rev. 10/2010)                                                                                                              Page 2 of 2