Contributions Bureau 
                                                                                             PO Box 6339, Helena, MT  59604-6339 
                                                                                                                         Telephone (406) 444-3834 
      
                                            Third Party Authorization Form 
 Employer 
  Montana UI Employer Account Number                          Federal ID Number 

  Owner/Officer/Partner  Name                                 Doing Business As 

  Mailing Address (Street or PO Box)                          City, State Zip Code 

  Telephone Number                                            Email Address 

 Third Party Administrator (TPA) 
  Authorized Third Party Administrator                        Federal ID Number 

  Mailing Address (Street or PO Box)                          City, State Zip Code 

  Telephone Number                                            Email Address 

  Begin Authority As Of (date)                                 

                                            CONSENT & AUTHORIZATIONS 
  
 I hereby certify the above-named Third-Party Administrator (TPA) will be acting on behalf of my organization in matters 
 related to Montana Unemployment Insurance (UI).  
  
 UI eServices for Employers: I authorize the Montana Department of Labor & Industry, Unemployment Insurance Division 
 (UID) to grant employees of the above named TPA access to my UI account via UI eServices for Employers to receive and 
 respond to all matters concerning UI (check one): 
  
        Contributions (tax)                   Benefit Claims                               Both tax and benefit claim matters 
  
 Correspondence: I understand by authorizing UI eServices for Employers access to the above TPA, they will have 
 access to correspondence through eServices regarding my UI account and/or benefit claims filed. In addition, I authorize 
 the following correspondence to be mailed directly to the above TPA (check all that apply): 
  
        UI Tax Rate Notices                   Quarterly or monthly benefit charge notices 
   
        Benefit Claim related correspondence including Separation and Potential Charge notices. 
                                                              
                                            Signature of the Employer/Taxpayer 
 I relieve the Department and their representatives of any liability related to release of such information to the above-named authorized third-
 party agent.  I understand this authorization does not absolve me, as the employer/taxpayer, of the responsibility to ensure all quarterly 
 reports, taxes, and/or notices related to UI benefit claims are filed, paid, and/or responded to timely and accurately.  Any authorization 
 granted remains in effect until revoked by the taxpayer or the third-party agent. 
 
 The person completing this section and signing below must have legal authority to bind the business.                     
  I certify I have the legal authority to execute this form and authorize disclosure of  
  information noted above: 
  PRINTED NAME & TITLE of Authorized Person                                              PRINTED NAME of Witness to Authorized Person (Required) 

  SIGNATURE of Authorized Person                   DATE                                  SIGNATURE of Witness (Required)      DATE 

 Instructions for Completing Authorization Form: 

  • Ensure both the Employer and Third-Party Agent (TPA) sections are completed. Note: If you have multiple third- 
    party agents performing UI related services for you, you will need to complete a separate authorization form for 
    each of them. 
  • A person authorized to bind the business must sign in the Signature Section. Authorized signers may include an: 
    owner, corporate officer, partner, managing member, Chief Financial Officer, Chief Executive Officer, or a fiduciary 
    of a trust or estate. 
  • A witness to the above signature, must also sign and date the form. 
  • Return the form to UI Contributions electronically through upload into UI eServices for Employers 
    (uieservices.mt.gov).