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Form Dfc041 - Limited Power Of Attorney Form - Department Of Employment-Employer Services

DFC041

Department of Employment-Employer Services

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:

The presenting of completed forms, including claims for refund or adjustment of account,

employer’s protest of benefit claims, and information relative thereto.

All matters affecting merit rating, contributions and/or direct reimbursements.

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.

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 10-8-2007

Form Dfc041 - Limited Power Of Attorney Form - Department Of Employment-Employer Services