State of Wyoming 

                                   Department of Workforce Services 
                                        Unemployment Tax Division 
                                                       PO Box 2760                          Robin Sessions Cooley, J.D. 
  Mark Gordon                                 Casper, Wyoming 82602                               Director 
                                                                                                  Elizabeth Gagen, J. D. 
       Governor                         307-235-3217Fax:   307-235-3278                          Deputy 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                Robin Sessions Cooley, J.D. 
 Mark Gordon                               Casper, Wyoming 82602           Director 
                                                                           Elizabeth Gagen, J. D. 
      Governor                     307-235-3217Fax: 307-235-3278          Deputy 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)