Reimbursable Employers Power Of Attorney {DOL-14}

GEORGIA, COUNTY GA. DOL ACCOUNT NO. FOR DEPARTMENT USE ONLY REIMBURSABLE EMPLOYER'S POWER OF ATTORNEY , an employer liable under OCGA Sections (employer) 34-8-33(a)(4) or (5) or 34-8-35(h) and (i) of the Employment Security Law, has elected under subsection (b) of OCGA Section 34-8-158 of the Employment Security Law to reimburse the Georgia Department of Labor an amount equal to the sum of all regular benefiits paid and one-half of any extended benefits paid, which are attributable to service in the employ of such employer; and WHEREAS, this employer has been approved under subsection (b)(5) of OCGA Section 34-8-160 of the Employment Security Law to deposit acceptable securities in lieu of either the cash deposit or surety bond required by subsection (a); and WHEREAS, WHEREAS, (employer) name (Give full description of Security) , has purchased in its own of total value of $ for the purpose of substituting for the above described cash deposit or surety bond; and WHEREAS, these securities along with a copy of this Power of Attorney properly executed will be deposited in the (Name and Address of Bank) for safekeeping. NOW, THEREFORE, pursuant to the terms of the Employment Security Law: KNOW ALL MEN BY THESE PRESENTS, that the undersigned officer of the , pursuant to authority granted him to (employer) on behalf of (employer) appoints the Georgia Department of Labor the true and lawful Attorney in Fact for (employer) In the event of default by to act in its place and stead, as follows: , hereby constitutes and , the (employer) Attorney in Fact is hereby authorized and empowered to give notice of redemption of the subject Security to the obligor Bank in writing and pursuant to the terms of the Security and the Rules and Regulations of their issue, upon receipt of which notice of redemption the obligor Bank shall be authorized and directed to redeem said Security pursuant to the terms thereof and to pay all sums due thereunder directly to the Georgia Department of Labor for application by that Department. DOL-14 (R-11/08) American LegalNet, Inc. www.FormsWorkFlow.com This Power of Attorney, being coupled with an interest in the Employment Security Law, shall be irrevocable by as long as said (employer) employer is a reimbursable employer. This Power of Attorney shall remain in force as long as any obligations remain due thereunder and until there shall be revocation of this Power by both (employer) and the Attorney in Fact and written proof thereof to obligor Bank. The obligor Bank shall honor this Power of Attorney but shall be under no obligation for the proper application of funds that are forwarded to the Georgia Department of Labor. IN WITNESS WHEREOF, set its official hand and seal this day of has hereunto , 20 . (Employer) ATTEST: BY (Signature of Officer) (Person who is authorized to sign this Power of Attorney must attach his authorization to sign for the named employer.) NOTICE OF RECEIPT OF SECURITY BY DEPOSITORY BANK: Receipt of securities described herein is hereby acknowledged and such security will not be released unless written authority is received from the Attorney in Fact. (Date) (Signature of Bank Official) (Title) If you have any questions with respect to this form, call (404) 232-3310. American LegalNet, Inc. www.FormsWorkFlow.com