State of Tennessee
Department of Labor and Workforce Development
Employer Services Unit
220 French Landing Drive, Floor 3-B
Nashville, Tennessee 37243-1002
DECLARATION OF REPRESENTATIVE
This is to certify that (Representative): _____________________________________________________________
Located at: ___________________________________________________________________________________
City: _______________________________________ State: ______ Zip Code: _________________________
Phone: ________________________________ Fax: ________________________________
is authorized to represent (Employer): _____________________________________________________________
Employer’s Federal Employer Identification Num
ber: _________________ Applied For
Employer’s Tennessee Employer Account Number: _________________ Applied For
before the Tennessee Department of Labor and Workforce Development (TDLWD) for the item(s) checked below:
for completing and filing
quarterly Premium and Wage Reports
for benefit charge management*
*Benefit Charge Management includes receiving and responding to any time sensitive request(s) for separation information and
notice(s) of claim filed and, responding to any summary of benefits charged. It also includes representation for the purpose of
filing appeals and appearance in connection with those appeals before Appeal Boards of the TDLWD.
Summaries of benefits charged are mailed to the primary address of record.
uuuuuuuuuuuuuuuuuuuu
This authorization supersedes all similar authorizations. This form also authorizes the TDLWD to, in accordance with
applicable law, release to the Representative any documentation relating to the Employer’s account that it could release to the
Employer.
Employer Name:
Trade
Name: _____________________________________________________________________
Mailing
Address: _____________________________________________________________________
____
_________________________________________________________________
Required:
Authorized Employer Signature: ____________________________________________ Date: ______________
Print Name of Signer: _______________________________________ Title: ___________________________
Return to: Tennessee Department of Labor and Workforce Development
Employer Services Unit
Pho
ne: 615-741-2486
220 French Landing Drive, Floor 3-B
Nashville, TN 37243
Fax
: 615-741-7214
LB-0927
(Rev. 07-14) RDA 1559
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP New Hampshire.
