REVOCATION OF WRITTEN AUTHORIZATION
GRANTOR INFORMATION
IMPORTANT MUST provide Grantor’s Current Mailing Address
By
Printed name, signature and title of the Grantor or the Grantee)
*(10) Date Signed
To the Grantor
TEXAS WORKFORCE COMMISSION
NOTE
*MANDATORY INFORMATION
Clear Form
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SAVE
THIS FORM IS REQUIRED BY TWC IN ORDER TO REVOKE
AUTHORIZATION FOR ANY THIRD PARTY ADMINISTRATOR
OTHER THAN ADP UNEMPLOYMENT CLAIMS.
INSTRUCTIONS FOR REVOCATION OF WRITTEN AUTHORIZATION
*
NOTE
Important
Printed name, signature and title of Grantor or Grantee: