Fillable Printable Limited Power of Attorney - Wyoming

Limited Power of Attorney - Wyoming

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