Claimants and Employers may designate representatives to assist in any aspect of the Division’s wage complaint process. The
wage complaint process includes the investigation conducted by the Division’s Compliance Investigators and the appeals
process through the Division’s Hearing Officer. Representatives may be attorneys, non-attorneys, relatives, non-relatives,
organizations.
To complete this form:
1.
Fill in your information (Section I) and the
information for the third party representative (Section II).
2.
Sign and date the authorization statement (Section III).
3.
Submit the completed form to the Division by email, fax, mail, or in person. Once submitted, you may only revoke this
authorization by providing written notice to the Colorado Division of Labor Standards and Statistics.
Section II: Authorized Representative Information
(can be a person or organization who represents the individual listed in Section I throughout the Division’s wage complaint process)
First Name of Authorized Representative Last Name of Authorized Representative
Name of Authorized Representative Organization (if applicable)
Mailing Address for Authorized Representative
City State Zip Code
Phone Number Fax Number
Email Address
Section III:
I, __________________________________________________________ (your name), hereby authorize the following:
1. The Division
is authorized to release, furnish, provide, exchange and request any and all information concerning the
specific wage complaint to the above listed authorized representative.
2. The above listed authorized representative can release, furnish, provide, exchange and request any and all information
concerning the specific wage complaint to the Division.
3. The above authorized representative can make any and all decisions related to the specific wage complaint on my behalf.
4. By typing your name below in the signature line, you represent that you are the individual identified as the wage
complainant/employer at the top of this form.
Your Full Name Your Signature Date
Colorado Division of Labor Standards and Statistics
AUTHORIZED REPRESENTATIVE FORM
(for Claimants & Employers to designate a representative with the Division’s
Wage Complaint Process)
.
Office Use Only:
CLAIM #:
COMP
INVEST:
6
33 17
th
Street, Suite 600
Denver, Colorado 80202-2107
Telephone (303) 318-8441
Fax (303) 318-8400
Toll Free (888) 390-7936
www.colorado.gov/cdle/labor
Last updated August 2016
Section I: Your Contact Information (to be filled out by the Claimant or the Employer)
Your First Name Your Daytime Phone
Your Last Name Your Alternate Phone
Your Mailing Address
City State Zip Code
Your Email Address
Name of Employer/Business/Company
