Mail To: 
Cashier - Texas Workforce Commission 
P.O. Box 149037 
Austin, TX 78714-9037 
512.463.2731 
www.texasworkforce.org    
                                                                                  
                           REVOCATION OF WRITTEN AUTHORIZATION 
   To revoke Written Authorization previously granted and on file with Texas Workforce Commission 
1.  REVOCATION SUBMITTED BY:                                                                  GRANTOR INFORMATION:      
    CHECK APPROPRIATE BOX:                                                                    2.   TWC ACCOUNT NO.                                
     A.          Grantor                                                                      3.  FEID NO.                                        
    B.           Grantee with Written                                                         4.  TELEPHONE NO.                                   
               Authorization on file with TWC                                                  
 
THIS INSTRUMENT revokes, recalls, and makes void that Written Authorization heretofore granted  
 
*(5) to                                                                                                                           , to represent 
             (Grantee) 
                                                                                               
*(6)                                                                                                                              , an employing unit,  
      (Grantor) 
 
(7) which is a/an                                                                                                                                      
                                                                   (Individual, Partnership, or Corporation, etc.) 
 
*(8) and whose address is                                                                                                                              
                                                                    (IMPORTANT:  MUST provide Grantor’s Current Mailing Address.) 
 
in its relations with theTexas        Workforce Commission. 
 
*(9) By:                                                                                                                                               
                                     (Printed name, signature and title of the Grantor or the Grantee) 
 
*(10) Date Signed                                                                                                                                  
 
To the Grantor:  This Revocation of Written Authorization referred to above has been filed and the 
records of this Commission have been marked accordingly. 
                                                                       
TEXAS WORKFORCE COMMISSION 
                                      
By:                                                                                                                                              
                       Signature                                                              Title                                 Date 
                                                                                                                                                       
NOTE:  This Revocation of Written Authorization should be executed and sent to the Texas Workforce Commission, Austin, Texas, to be filed.  It will be 
processed and signed in this office and returned to the Grantor as evidence of receipt.  
 
*MANDATORY INFORMATION                                                                                                                                 
                                                                                               (11) TWC ACCOUNT NO. FOR GRANTEE (if applicable) 
 
Form C-43 (061812)                                                              (Page 1 of 2) 

Mail To: 
Cashier - Texas Workforce Commission 
P.O. Box 149037 
Austin, TX 78714-9037 
512.463.2731 
www.texasworkforce.org   
 
                INSTRUCTIONS FOR REVOCATION OF WRITTEN AUTHORIZATION            
                To revoke Written Authorization previously granted and on file with the TWC. 
 
Description of information required on front of document.  *Failure to complete the items with an 
asterisk (*) will result in the document being returned as incomplete. 
  
  1.     NOTE:  The Grantee submitting a Revocation must have an approved Written Authorization 
         on file with the Texas Workforce Commission.  It is very important that you check appropriate 
         Block A or B.  
 
  2.  Account Number assigned by the Texas Workforce Commission to Grantor. 
 
  3.  Federal Employer Identification Number of the Grantor. 
 
  4.  Grantor's telephone number including Area Code. 
 
  *5.  Name of Grantee. 
 
  *6.  Name of Grantor as it appears on Employer’s Quarterly Reports. 
 
  7.  Type of Ownership, (Individual, Partnership, or Corporation, etc.) 
 
  *8.    Important:  Grantor’s current mailing address is required. 
 
  *9.    Printed name, signature and title of Grantor or Grantee:  
         A Revocation of Written Authorization must be signed by (1) the individual, if the Grantor is a  
         sole proprietor; (2) a responsible and duly authorized member or officer having knowledge of  
         its affairs, if the Grantor is a partnership or other unincorporated organization; (3) the  
         president, vice president, or other principal officer, if the Grantor is a corporation; (4) the  
         fiduciary, if a trust or estate; or, (5) the Grantee, if applicable.  
 
 *10.  Date Signed.  
 
  11.  This item to be completed by Grantee, if applicable.  
 
                      Individuals may receive, review and correct information that TWC collects  
                about the individual by emailing to open.records@twc.state.tx.us or writing  
                                               th
                to TWC Open Records, 101 E. 15  St., Rm. 266, Austin, TX  78778-0001. 
                                                  
Form C-43 (061812)                       (Page 2 of 2)