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) 
Sign, date, and submit original and amended wage 
reports on behalf of the employer.                       
Submit payments on behalf of the employer/taxpayer. 
                                                         
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