State of Wyoming 
                    Department of Workforce Services 
                       DIVISION OF WORKERS’ COMPENSATION                                                              
                                     5221 Yellowstone Road                 Robin Sessions Cooley 
                                     Cheyenne, Wyoming 2009                                                Director 
  Mark Gordon                        307.777.6763   Fax: 307.777.5298                                      
   Governor                                                                Elizabeth Gagen, J.D. 
                                     www.wyomingworkforce.org              Deputy Director 
                                                                                                            
             AFFIDAVIT AFFIRMING AMOUNT OF MONTHLY PAYROLL 
 
EMPLOYER:         _________________________________         EMPLOYER #: __________________ 
                   
Effective July 1, 2018, Wyoming Workers’ Compensation modified its requirements for Non-Resident 
Employer Collateral Requirements.  A Surety Bond, Letter of Credit, or an Advance Cash Premium is 
not required for employers with an average monthly payroll of $4,000.00 a month or less. 
 
Read the following statements and sign the affidavit below.  Submit the signed copy to any of the 
Division’s field offices or send to: 
 
                      WYOMING WORKERS’ COMPENSATION 
                      EMPLOYER SERVICES – TAX DIVISION 
                                     5221 YELLOWSTONE ROAD 
                                     CHEYENNE WY   82009 
                                                       
  I, the undersigned, do affirm that total monthly (or anticipated payroll) for this account is  
  $_________________. 
 
  If the total monthly payroll exceeds $4,000.00, I do hereby acknowledge that a Surety Bond, Letter  
      of Credit, or an Advance Cash Premium will be furnished to all Departments of Workforce Services. 
  _______________________________________                   _______________________________ 
  Print Name                                                Title 
                                                                        
  _______________________________________                   _______________________________ 
  Signature                                                 Date 
     
                                     Penalty for Failure to Post Bond: 
   Wyoming Statute 27-14-307 states “The willful failure of any nonresident employer in a covered employment to 
   give bond or other security required by this act constitutes a misdemeanor, punishable by a fine of not more than 
                 five thousand dollars ($5,000.00), imprisonment for not more than one (1) year, or both”. 
   
 BOND 
 Page 2 of 5        As public servants, we work hard every day to help     EMPLOYER SERVICES 
 Revised 02/2020    ensure safe and fair workplaces with qualified workers                                 PHONE: 307-777-6763 
                                                                                                           FAX: 307-777-5298 
                                                                           www.wyomingworkforce.org