State of Tennessee 
                       Department of Labor and Workforce Development 
                                     Employer Services Unit 
                                     220 French Landing Drive, Floor 3-B 
                                     Nashville, Tennessee 37243-1002 

                       DECLARATION OF REPRESENTATIVE 

This is to certify that (Representative): _____________________________________________________________ 

Located at: ___________________________________________________________________________________ 

City: _______________________________________  State: ______  Zip Code: _________________________ 

Phone: ________________________________        Fax: ________________________________

is authorized to represent (Employer): _____________________________________________________________ 

 Employer’s Federal Employer Identification Number:            _________________ Applied For                

 Employer’s Tennessee Employer Account Number:                 _________________ Applied For    

before the Tennessee Department of Labor and Workforce Development (TDLWD) for the item(s) checked below:  

           for completing and filing                                       for benefit charge management* 
         quarterly Premium and Wage Reports 
*Benefit Charge Management includes receiving and responding to any time sensitive request(s) for separation information and
notice(s) of claim filed and, responding to any summary of benefits charged. It also includes representation for the purpose of
filing appeals and appearance in connection with those appeals in administrative appeals before the TDLWD.
Summaries of benefits charged are mailed to the primary address of record. 
                                  uuuuuuuuuuuuuuuuuuuu 
This authorization supersedes  all similar authorizations.  This form  also authorizes the TDLWD to, in accordance with 
applicable law, release to the Representative any documentation relating to the Employer’s account that it could release to the 
Employer.
 Employer Name: 

 Trade Name:         _____________________________________________________________________

 Mailing Address:    _____________________________________________________________________ 

                     _____________________________________________________________________
Required: 
 Authorized Employer Signature: ____________________________________________  Date: ______________ 

 Print Name of Signer: _______________________________________    Title: ___________________________ 
Return to: Tennessee Department of Labor and Workforce Development 
           Employer Services Unit                                          Phone: 615-741-2486
           220 French Landing Drive, Floor 3-B 
           Nashville, TN 37243                                             Fax:  615-741-7214
LB-0927 (Rev. 10-23)                                                                                        RDA 1559