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Signature Name of Employer By Title Date LE-10 Rev. 3/13 Page 1 of 1 UI-1M Rev. 3/13 STATE OF ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY 33 SOUTH STATE STREET CHICAGO IL 60603-2802 UNEMPLOYMENT INSURANCE SPECIAL MAILING FORM The purpose of this form is to notify the Department of a request to have correspondence sent to an address other than your business address or to terminate a preexisting address. State of Illinois Department of Employment Security 33 South State Street Chicago IL 60603-2802 Power of Attorney for Representing Employer under the Illinois Unemployment Insurance Act Fax 312-793-6296 Account No* Employer located at Street Address City State Zip Code Telephone Number E-mail Address hereby authorizes to represent the Employer before the Director in any and all matters to act in the Employer s stead with the same consequences as the Employer and to receive any and all information requested by said Representative pertaining to the Employer s liability for the payment of contributions interest and penalties under the Illinois Unemployment Insurance Act until such time as the appointment is terminated* I understand that my Representative shall be provided information only to the extent that it is requested for one of the purposes set forth in Section 1900 of the Illinois Unemployment Insurance Act 820 ILCS 405/1900. If the requested address being added is for a third party or service bureau you must also complete the Power of Attorney LE-10 form* Employer Name DBA Name Illinois UI Account Number Federal I. D. Number Note Each form can be directed to only one address. Therefore check only once for each form* If your request cannot be contained in its entirety on this form because of multiple addresses please provide additional copies of the form BIS-32 Notice to Chargeable Employer UI-3/40 Contribution Wage Report Ben-118/118R Benefit Charge Notice UI-5A/UI5B Rate Notice Benefit Appeal Notice SI-5 Notice of Benefit Earnings Audit C/O Name of Representative or Service Bureau Unit or Suite City State ZIP Country Effective Date Termination Date Signed by. If the requested address being added is for a third party or service bureau you must also complete the Power of Attorney LE-10 form* Employer Name DBA Name Illinois UI Account Number Federal I. D. Number Note Each form can be directed to only one address. Therefore check only once for each form* If your request cannot be contained in its entirety on this form because of multiple addresses please provide additional copies of the form BIS-32 Notice to Chargeable Employer UI-3/40 Contribution Wage Report Ben-118/118R Benefit Charge Notice UI-5A/UI5B Rate Notice Benefit Appeal Notice SI-5 Notice of Benefit Earnings Audit C/O Name of Representative or Service Bureau Unit or Suite City State ZIP Country Effective Date Termination Date Signed by.

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