Prototype- Ohio JFS 20106 Employer’s Representative Authorization

Ohio JFS 20106 Employer’s Representative Authorization

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Ohio JFS 20106 Employer’s Representative Authorization

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Employer Legal Name*

First NameLast Name
Employer Email*
example@example.com
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
I hereby acknowledge that by signing this document I relieve the Ohio Department of Job and Family Services from any liability arising from the exercise of rights and causes of action on account of or growing out of failure of the undersigned to receive any correspondence sent to the representative indicated in Section III, including, but not limited to:
1. Notification required by Section 4141.26;
2. Injury caused by untimely appeal.
This authorization, voluntarily given by the undersigned, shall remain in full force and effect until such time as the agency is notified in writing by the undersigned or by the designated representative that the relationship has been dissolved.
Date of Signature*

MonthDayYear
Date
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Employer Signature*

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Ohio JFS 20106 Employer’s Representative Authorization