POWER OF ATTORNEY FORM
Power of Attorney Form
Use this form to authorize an employer agent as a designated representative for a business account.
▪ This authorization allows the Employment Security Department to send and share confidential
information about the business listed with the designated representative. This includes information
pertaining to the Paid Leave and WA Cares programs.
▪ By law, the employer is liable for all acts taken or failure to act by the agent on the employer’s behalf for
any delegated roles assigned to the agent. The law that applies is WAC 192-500-015.
Complete the required information (*) requested below then fax to 833-535-2273.
Employer information
First Name* : Last Name* :
Legal Business Name* :
Whidbey Island Public Ho
Employer Identification Number (EIN)* : Unified Business Identifier Number (UBI)* :
91-0843135 516 785 213
Mailing Address:
6888 Sierra Center Pkwy
City : State : Zip Code :
Reno NV 89511
Phone Number* : Email Address* :
888-927-7478
Employer agent information
First Name* : Last Name* :
Micah Sampson
Legal Business Name* :
PayCycle, Inc.
Employer Identification Number (EIN)* : Title* :
94-3345425 Operations Manager
Employer Agent ID* : A 2 0 0 0 0 0 0 0 6
Don’t have an Agent ID? Register with us to receive an employer Agent ID.
Go to [Link]/employer-agents to learn how to create your account.
Phone Number* : (888) 927-7478 Email Address* : tax_eservice@[Link]
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POWER OF ATTORNEY FORM
Authorizations
Select the role(s) you authorize this employer agent to act on and receive correspondence for :
✔ Wage Reporting | File quarterly wage reports and view wage submission history
✔ Wage Amendments | File wage amendments
Payments | Make payments and view billing statements
✔
Audits | Participate in Paid Leave and WA Cares audits
Appeals and Agreements | Enter into agreements and make oral or written presentation of fact and argument
Benefits | View Paid Leave benefit information for employees
Employer certification and signature
By signing below, I certify under penalty of perjury that:
• I am the business owner or officer duly authorized to represent this account.
• The information submitted has been examined by me and that the matters and statements set forth are true,
correct, and complete.
Authorization Effective Start Date* :
Authorization Effective End Date :
If no end date is provided, authorizations will remain in effect until revoked.
Employer Signature* : Date Signed* :
Printed Name* :
Steven Auerbach Managing Member
Employer agent certification and signature
By signing below, I certify under penalty of perjury that:
• I, and any delegated individual representing my agency, am duly authorized to represent this account.
• The information submitted has been examined by me and that the matters and statements set forth are true,
correct, and complete.
Employer Agent Signature* : Date Signed* :
08/21/2025
Printed Name* : Micah Sampson Title* : Operations Manager
The Employment Security Department is an equal opportunity employer/program. Auxiliary aids and services are
available upon request to individuals with disabilities. Language assistance services for limited English proficient
individuals are available free of charge. Washington Relay Service: 711
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