State of Wyoming 
                                 Department of Workforce Services 
                                      Unemployment Tax Division                                                  
                                                     PO Box 2760 
  Mark Gordon                               Casper, Wyoming 82602                               Robin Sessions Cooley 
     Governor                       307-235-3217  Fax: 307-235-3278                                   Director 
                                      www.wyomingworkforce.org 
 
                                    POWER OF ATTORNEY 
I.  Business/Taxpayer 
Name 
       
Address                                              City                                 State        ZIP Code 
                                                                                                             
Phone Number                     FEIN                                            UI Tax Number 
                                                                                       
II.  Does Hereby Appoint 
Name of Appointed Representative                                                          Phone Number 
                                                                                                
Address                                              City                                 State        ZIP Code 
                                                                                                             
as attorney(s)-in-fact to represent taxpayer before the Wyoming Unemployment Tax Division with respect to the 
following Unemployment Insurance matter(s): 
  •       The presenting of completed forms, including claims for adjustment of account, 
          employer’s protest of benefit claims and information relative thereto. 
  •       All matters affecting merit rating, contributions and/or direct reimbursements. 
  •       The personal discussion of  any or all of the foregoing with proper officials of  the State of Wyoming 
          Unemployment Tax Division, Unemployment Insurance Division, and the Workers’ Safety and Compensation 
          Division. 
  •       This appointment supersedes and replaces any prior authorization which our company may have filed with your 
          agency. 
III.  Authorize Access (please initial your choice) 
  ______   Tax Mailing Address (this allows your representative to receive all correspondences regarding your 
               Unemployment Tax account at their address. No correspondence will be mailed to you) 
  ______   Benefits Mailing Address (this allows your representative to receive all correspondences regarding 
               Unemployment claims at their address. No correspondence will be mailed to you) 
  ______   Both  
       ______  Information Only (all mail will be sent to your address. Your representative will still be able to view your  
               account and file reports as required) 
 
III.  Signature of Business Representative/Taxpayer 
Name (printed)                                       Title 
                                                                
Signature                                                                                 Date 
                                                                                                
                                                                                                       MODES-4444 (7/19)   

                                   State of Wyoming 
                Department of Workforce Services 
                                    Unemployment Tax Division                       
                                           PO Box 2760 
  Mark Gordon                              Casper, Wyoming 82602         Robin Sessions Cooley 
     Governor                      307-235-3217  Fax: 307-235-3278       Director 
                                    www.wyomingworkforce.org 
 
IV.  Signature of Appointed Representative 
I certify that I will represent this employer as a Third Party only. The employer has established their own account 
in WYUI and has requested an Association.  I will access their WYUI information and file quarterly reports only 
through my Third Party login. 
Name (printed)                                    Title 
                                                             
Signature                                                           Date 
                                                                          
V.  Mail or fax completed form to: Unemployment Tax Division 
                                   PO Box 2760 
                                   Casper, Wyoming 82602 
                                   Fax: 307-235-3278 
                                    
                                                                          MODES-4444 (7/19)