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Get MI UIA 1488 2012

R if you wish to revoke or change your current Power of Attorney representation. Please read the instructions on page 2 before completing this form. PART 1: EMPLOYER INFORMATION Name and Address (if individual) If a business, enter DBA, trade or assumed name. Telephone Number (required) Extension FEIN Number Fax Number UIA Account Number ** E-mail Address (if applicable) PART 2: REPRESENTATIVE INFORMATION AND AUTHORIZATION DATES Your authorized representative may be an organization, firm,.

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