KANSAS DEPARTMENT OF LABOR
                                                                                                                      MAIL: Kansas Department of Labor 
       www.dol.ks.gov                                                                                                       UI Tax Contributions
                                                                                                                            401 SW Topeka Blvd. 
EMPLOYER REPRESENTATIVE AUTHORIZATION                                                                                       Topeka, KS 66603-3182
       K-CNS 032 (Rev. 12-21)
                                                                                                                      FAX:  (785) 291-3425

Request will be denied if any item is incomplete.

       Employer Serial Number: ______________________

       Employer: ______________________________________________________________________________________________________

       Physical address of business in KANSAS. If no physical address, store front or business location exists in KANSAS, you must indicate 
       where in KANSAS     you have workers performing a service. Do NOT use a Post Office Box number.

              Business location                                   Job site                                   Company representative residence
              Other      (explain): _______________________________________________________________________________________

       ______________________________________________________________________________________________________________
       Address (Do NOT use PO Box number)                                                      City                                                            State               ZIP

       Representative retained to represent you: _____________________________________________________________________________
       Representative’s phone: __________________________________(         )                  Representative’s email: _____________________________________
       Indicate which Kansas unemployment insurance reports you have delegated the authority to receive. Provide the mailing address for the 
       delegated reports.

             Employer’s Quarterly Wage Report and Unemployment Tax Return, K-CNS 100

              Name: ___________________________________________________________________________________________________

              Address: __________________________________________________________________________________________________

              City, State, ZIP: ___________________________________________________________________________________________

             Annual Experience Rating Notice, K-CNS 404, and Annual Notice of Benefit Charges, K-CNS 403

              Name: ___________________________________________________________________________________________________

              Address: __________________________________________________________________________________________________

              City, State, ZIP: ___________________________________________________________________________________________

             Last Employer, Base Period and all other Benefit and Appeal Claim Notices

              Name: ___________________________________________________________________________________________________

              Address: _________________________________________________________________________________________________

              City, State, ZIP: __________________________________________________________________________________________

       _________________________________________________________________________________  _____________________________
       Owner, partner, corporate officer, LLC member/manager signature                                                                                 Date (mm/dd/yyyy)

       ___________________________________________________________  __________________________________________________(            )
       Email                                                                                  Phone

              More information about filing reports as an authorized employer representative is found at www.KansasEmployer.gov.

                                             UNEMPLOYMENT TAX CONTRIBUTIONS
                             401 SW Topeka Blvd., Topeka, KS 66603-3182 • Phone (785) 296-5027 • Fax (785) 291-3425