Get Employer Representative Authorization Form - Acumen Fiscal Agent

The Employer Representative Authorization Form allows users to designate a representative, such as a third-party administrator, to manage correspondence regarding their account. This guide provides clear, step-by-step instructions for completing this form online, ensuring a smooth process that meets your needs.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter your employer information: print your name, employer name, employer account number, plant number (if applicable), and employer phone number.
3. Provide the representative or third-party administrator's name, number, and contact information, including their address (Line 1 and Line 2, if necessary), city, state, and ZIP code.
4. In Section II, choose whether you are authorizing the representative or dissolving the authorization. Check the appropriate box to inform the Ohio Department of Job and Family Services.
5. In Section IV, provide your signature and title, then enter the date of signing. This signature acknowledges your agreement and relieves the agency from liability as described in the section.
6. Once all sections are completed, save your changes. You can then choose to download, print, or share the completed form as needed.

Complete your Employer Representative Authorization Form online today to ensure timely management of your account.