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Wyoming Limited Power of Attorney Form


Wyoming Limited Power of Attorney Form
Wyoming Limited Power of Attorney Form
DFC041
Wyoming Unemployment Tax Division
LIMITED POWER OF ATTORNEY
UNEMPLOYMENT INSURANCE WORKERS’ COMPENSATION
ACCOUNT #: ________________ EMPLOYER #: ________________
EMPLOYER NAME: ____________________________________________________________
EMPLOYER ADDRESS: ________________________________________________________
_____________________________________________________________________________
TO WHOM IT MAY CONCERN:
I/We have appointed __________________________________________________ as our
agent to represent our company in Unemployment Insurance and/or Workers’ Safety and
Compensation matters until further notice.
Authorized agent’s telephone number: ____________________
This representation includes:
1. The presenting of completed forms, including claims for refund or adjustment of account,
employer’s protest of benefit claims, and information relative thereto.
2. All matters affecting merit rating, contributions and/or direct reimbursements.
3. The personal discussion of any or all of the foregoing with proper officials of the State of
Wyoming Unemployment Tax Division, Unemployment Insurance Division, and the Workers’
Safety and Compensation Division.
4. This appointment supersedes and replaces any prior authorization which our company may
have filed with your agency.
Authorized by: ________________________________ Title: _______________________
Phone #: ____________________ Date: _______________________
RETURN TO: DEPT OF EMPLOYMENT
Unemployment Tax Division
Employer Services
P O Box 2760
Casper WY 82602-2760
FAX: 307-235-3278
POA 7-25-05
Wyoming Limited Power of Attorney Form