State of Wyoming  

                              Department of Workforce Services 
                              WORKERS'     COMPENSATION - EMPLOYER SERVICES                                                     
                                             5221 Yellowstone Rd                        Robin Sessions Cooley 
       Mark Gordon 
                                            Cheyenne, Wyoming 82002                                             Director 
             Governor 
                                                                                                                 
               AFFIDAVIT AFFIRMING AMOUNT OF MONTHLY PAYROLL 
       
      EMPLOYER:          _________________________________          EMPLOYER #: __________________ 
                          
      Effective July 1, 2018, Wyoming Workers’ Compensation modified its requirements forNon-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 DEPT OF WORKFORCE SERVICES 
                            WORKERS’ COMPENSATION -           EMPLOYER SERVICES 
                                           5221 YELLOWSTONE RD                 
                                            CHEYENNE WY   82002  
                                                           
            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 toall 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”. 
             
                                                                                                                EMPLOYER 
                                                                                                                SERIVCES 
       BOND                                                                             Phone 1-307-777-6763 
       Page 2 of 5                                                                      Fax 1-307-777-5298 
                                                                                        Wyomingworkforce.org