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 before Appeal Boards of 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. 07-14)                                                                                      RDA 1559