DFC041
POA 8-25-17
DEPARTMENT OF WORKFORCE SERVICES
LIMITED POWER OF ATTORNEY
EMPLOYER NAME: ___________________________________________________________
EMPLOYER ADDRESS: ________________________________________________________
WORKERS’ COMPENSATION UNEMPLOYMENT INSURANCE
EMPLOYER #______________ EMPLOYER #_______________
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: ____________________
Authorized agent’s address: ___________________________________________________
__________________________________________________________________________
This representation includes:
1. The presenting of completed forms, including claims for refund or adjustment of account,
employer’s protest of benefit claims, and information relative thereto.
2. All matters affecting merit rating, contributions and/or direct reimbursements.
3. 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.
4. This appointment supersedes and replaces any prior authorization which our company may
have filed with your agency.
Authorized by Title ___________________________
Phone # Date ___________________________
RETURN TO:
WORKERS’ COMPENSATION UNEMPLOYMENT TAX DIVISION
EMPLOYER SERVICES or EMPLOYER SERVICES
1510 EAST PERSHING BLVD P O BOX 2760
CHEYENNE, WY 82001 CASPER, WY 82602-2760
FAX: 307-777-5298 FAX: 307-235-3278
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP New Hampshire.
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PO BOX 17617 MISSOULA MT 59808-7617
