Wyoming Limited Power of Attorney Form
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DFC041

Wyoming Unemployment Tax Division
LIMITED POWER OF ATTORNEY

UNEMPLOYMENT INSURANCE
ACCOUNT #: ________________

WORKERS’ COMPENSATION
EMPLOYER #: ________________

EMPLOYER NAME: ____________________________________________________________
EMPLOYER ADDRESS: ________________________________________________________
_____________________________________________________________________________

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: ____________________
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 o