Employer Representative Authorization

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KANSAS DEPARTMENT OF LABOR
MAIL:
Kansas Department of Labor
UI Tax Contributions
EMPLOYER REPRESENTATIVE AUTHORIZATION
401 SW Topeka Blvd.
Topeka, KS 66603-3182
K-CNS 032 (Rev. 2-14)
FAX:
(785) 291-3425
EMAIL:
uitax@dol.ks.gov
Request will be denied if any item is incomplete.
Employer Serial Number: ______________________
Employer: ______________________________________________________________________________________________________
Physical address of business in KANSAS. If no physical address, store front or business location exists in KANSAS, you must indicate
where in KANSAS you have workers performing a service. Do NOT use a Post Office Box number.
Business location
Job site
Company representative residence
Other (
): _______________________________________________________________________________________
explain
______________________________________________________________________________________________________________
Address (Do NOT use PO Box number)
City
State
ZIP
Representative retained to represent you: _____________________________________________________________________________
Indicate which Kansas unemployment insurance reports you have delegated the authority to receive. Provide the mailing address for the
delegated reports.
Employer’s Quarterly Wage Report and Unemployment Tax Return, K-CNS 100
Name: ___________________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City, State, ZIP: ___________________________________________________________________________________________
Annual Experience Rating Notice, K-CNS 404, and Annual Notice of Benefit Charges, K-CNS 403
Name: ___________________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City, State, ZIP: ___________________________________________________________________________________________
Last Employer, Base Period and all other Benefit and Appeal Claim Notices
Name: ___________________________________________________________________________________________________
Address: _________________________________________________________________________________________________
City, State, ZIP: __________________________________________________________________________________________
_________________________________________________________________________________ _____________________________
Owner, partner, corporate officer, LLC member/manager signature
Date (mm/dd/yyyy)
(
)
___________________________________________________________
__________________________________________________
Email
Phone
More information about filing reports as an authorized employer representative is found at
UNEMPLOYMENT TAX CONTRIBUTIONS
401 SW Topeka Blvd., Topeka, KS 66603-3182 • Phone (785) 296-5027 • Fax (785) 291-3425 • uitax@dol.ks.gov

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