Fillable EMPLOYER DESIGNATED MAILING ADDRESS FORM UI Support Services (ADP)

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EMPLOYER DESIGNATED MAILING ADDRESS FORM UI Support Services (ADP)

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EMPLOYER DESIGNATED MAILING ADDRESS FORM
UI Support Services - Attention Chargeback
Texas Workforce Commission
101 East 15
th
Street, Room 354
Austin, TX 78778-0001
TWC Account Number:
FAX: 512-305-8998- Attention Chargeback
You may designate a specific mailing address for TWC to use when mailing correspondence about unemployment
benefit claims and employer chargebacks. Fill out a new form if your address changes OR you stop using a Service
Representative company. Please see the designated claims and chargeback address information at
http://www.twc.state.tx.us/ui/bnfts/designated-mailing-addresses.html before filling out the section below.
The designated mailing address options are:
* Designated Claims Address and/or * Designated Chargeback Address
If you want TWC to use a designated claims and/or chargeback address, please complete the appropriate items below.
CLAIMS ADDRESS
Organization Name:
Additional Name:
TWC Tax Account Number:
Service Representative Company Name:
Mailing Address:
City:
State:
Zip Code:
Telephone Number:
Fax Number:
Contact Person:
Telephone Number:
Written Authorization (Form C-42): Attached On File With TWC Not Applicable
CHARGEBACK ADDRESS
Organization Name:
Additional Name:
TWC Tax Account Number:
Service Representative Company Name:
Mailing Address:
City:
State:
Zip Code:
Telephone Number:
Fax Number:
Contact Person:
Telephone Number:
Written Authorization (Form C-42): Attached On File With TWC Not Applicable
Employer’s Signature:
Date
Employer’s Title:
Mail or FAX this notice and any attachments to the
Texas Workforce Commission address located in
the upper left corner of the page.
Date Processed: ______
Commission Rep: ______
HEARING IMPAIRED CLIENTS call Relay Texas: 711
You may receive, review, and correct information TWC collects about you by contacting TWC Open Records at 1-866-274-0940.
BR-001 (10-11)
INSTRUCTIONS
DESIGNATED MAILING ADDRESS INFORMATION
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ADP UNEMPLOYMENT CLAIMS TPA #: 14-355520-8
PO BOX 16440
CLEARWATER
FL
33766-6440
855-537-8499
855-537-8536
855-537-8499
ADP UNEMPLOYMENT CLAIMS TPA #: 14-355520-8
PO BOX 16440
CLEARWATER
FL
33766-6440
855-537-8499
855-537-8536
855-537-8499
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EMPLOYER DESIGNATED MAILING ADDRESS FORM UI Support Services (ADP)

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Completed 8 February 2021

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