DIVISION OF UNEMPLOYMENT  NSURANCEI  
                                                                                         Employer Status Unit 
                                                                             1100 North Eutaw Street, Room 415 
                                                                                             Baltimore, MD 21201 

EMPLOYER             POWER  OF ATTORNEY AUTHORIZATION                 FORM   DESIGNATING     AGENT 

1. Maryland Unemployment Insurance Employer Number:

2. Federal Employer Identification Number:

3. Name of Employer/Taxpayer:

4. Address:

5. Telephone Number:                                         Email address: 

                                                    Reporting Agent 
1. Maryland Unemployment Insurance Agent Number:

2. Name of Reporting Agent:

3. Address:

4. Telephone Number:                                         Email address: 
                                                    Authorization 
Check the authorization that is granted to the Reporting Agent. (Check all that apply.) 
Authorization Type                                             Communication         Details 
                                                               Preference            (Mailing address / Email / 
                                                               (US Mail /            Phone number) 
                                                               Email / Text) 
Submit original and amended wage reports on 
behalf of the employer.                                      BEACON Inbox               See inbox for correspondence

Submit payments on behalf of the employer/taxpayer.          BEACON Inbox               See inbox for correspondence

Make account maintenance updates on behalf of the 
employer.                                                      

Access benefit charges and receive benefit charge 
statements on behalf of the employer.                          
Manage wage and separation requests on behalf of the 
employer, including receipt of notices regarding wage and      
separation issues.
File and participate in any adjudication before the Division 
of Unemployment Insurance and file and participate in any 
appeal hearing before either the UI Lower Appeals Division     
or the Board of Appeals. 

All of the above                                               

Revoke a previous Power of Attorney authorization.

     DLuiTaxEmployerStatus-DLLR@maryland.gov | 410-949-0033 | www.labor.maryland.gov

                                         MARYLAND DEPARTMENT OF LABOR 

                                                               DIVISION OF UNEMPLOYMENT  NSURANCEI      
                                                                            Employer Status Unit 
                                                                1100 North Eutaw Street, Room 415 
                                                                            Baltimore, MD 21201 

Effective Date of Authorization: 

End Date of Authorization (if applicable): 

                                 Signature and Acknowledgement 

The Employer/Taxpayer authorizes the Maryland Division of Unemployment Insurance to disclose otherwise 
confidential tax information to the Reporting Agent relating to the Authorization granted above, including any disclosure 
required to process this form. 

Full Name on behalf of Employer (Printed)  Title 

Signature on behalf of Employer            Date 

                                 MARYLAND DEPARTMENT OF LABOR