Form C-43 - Revocation Of Written Authorization
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1Mail To:
Cashier - Texas Workforce Commission
P.O. Box 149037
Austin, TX 78714-9037
512.463.2731
REVOCATION OF WRITTEN AUTHORIZATION
To revoke Written Authorization previously granted and on file with Texas Workforce Commission
REVOCATION SUBMITTED BY
GRANTOR INFORMATION:
1.
:
TWC ACCOUNT NO.
CHECK APPROPRIATE BOX:
2.
A.
Grantor
. FEID NO.
3
B.
Grantee with Written
. TELEPHONE NO.
4
Authorization on file with TWC
THIS INSTRUMENT revokes, recalls, and makes void that Written Authorization heretofore granted
to
to represent
*(5)
,
(Grantee)
, an employing unit,
*(6)
(Grantor)
which is a/an
(7)
(Individual, Partnership, or Corporation, etc.)
and whose address is
*(8)
(IMPORTANT: MUST provide Grantor’s Current Mailing Address.)
in its relations with the Texas Workforce Commission.
By:
*(9)
(Printed name, signature and title of the Grantor or the Grantee)
Date Signed
*(10)
To the Grantor: This Revocation of Written Authorization referred to above has been filed and the
records of this Commission have been marked accordingly.
TEXAS WORKFORCE COMMISSION
By:
Signature
Title
Date
NOTE: This Revocation of Written Authorization should be executed and sent to the Texas Workforce Commission, Austin, Texas, to be filed. It will be
processed and signed in this office and returned to the Grantor as evidence of receipt.
*MANDATORY INFORMATION
(11) TWC ACCOUNT NO. FOR GRANTEE (if applicable)
(Page 1 of 2)
Form C-43 (061812)
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