Form C-42 - Written Authorization To Represent Employing Unit In Its Relations With The Texas Workforce Commission
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1Texas Workforce Commission
Tax Department – Status Section
101 E 15th St – Rm 570
Austin TX 78778-0001
WRITTEN AUTHORIZATION
To represent employing unit in its relations with the Texas Workforce Commission
GRANTOR INFORMATION
CONTACT NAME: _____________________
TWC ACCT NO._______________________
1.
3.
PHONE NO. (
) ____________________
FEID NO. ___________________________
2.
4.
BY THIS INSTRUMENT, __________________________________________________________.
(5)
(Name of Grantor)
an employing unit which is a/an_____________________________________________________.
(6)
(Individual, Partnership, or Corporation, etc.)
whose address is________________________________________________________________.
(7)
(Grantor’s current mailing address)
appoints ______________________________________________________________________.
*(8)
(Name of Authorized Grantee)
whose TWC ACCOUNT NO. is _________________, and whose address is _________________,
(9)
_______________________________________________________________________________
its lawful representative to represent it in its relations with the Texas Workforce Commission, and
specifically authorizes said representative to transact any and all business as between grantor of said
authorization and said Commission to do any and all acts necessary, excluding litigation in court.
This Written Authorization shall be in full force and effect until such time as a Revocation of
Written Authorization, Form C-43, revoking it is filed in the office of said Commission at
Austin, Texas. (Revocable by either party, the Grantor or Grantee.)
*(10) _____________________________________________________________________________________________________________________
Printed name, signature and title (Owner, Partner, Officer, etc.) of person signing for Grantor.
SUBSCRIBED AND SWORN to before me on this the ________ day of ____________ ______
*(11)
(Month)
(Year)
*(12)
________________________________________________________
(Signature of Notary Public)
Notary Public, State of___________________
*(13)
(Notary Seal)
My Commission expires: _________ _______
(Month & Day)
(Year)
NOTICE: This Written Authorization should be executed in triplicate. Original to be filed with the
Texas Workforce Commission, Austin, Texas. One copy to be retained in the employer’s files and one
to be retained in Grantee’s files.
*MANDATORY INFORMATION
INSTRUCTIONS ON REVERSE SIDE
Form C-42(1199) Inv. No. 520950
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