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WRITTEN AUTHORIZATION (ADP)

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This Written Authorization shall be in full force and effect until such time as a Revocation of
Written Authorization, Form C-43, revoking it is filed in the office of said Commission at
Austin, Texas. (Revocable by either party, the Grantor or Grantee.)
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*MANDATORY INFORMATION
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Clear Form
PRINT
SAVE
ADP, LLC. (ADP UNEMPLOYMENT CLAIMS)
14-355520-8
PO BOX 16440 CLEARWATER FL 33766-6440
SIGN HERE - THIS MESSAGE WILL NOT PRINT.
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INSTRUCTIONS FOR WRITTEN AUTHORIZATION
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If the Grantor does not have a number, a Form C-1, Status Report, should be submitted.
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NOTE! WRITTEN AUTHORIZATION MAY BE REVOKED BY GRANTOR OR GRANTEE.
Individuals may receive, review and correct information that TWC collects
about the individual by emailing to open.records@twc.state.tx.us or writing
to TWC Open Records, 101 E. 15
th
St., Rm. 266, Austin, TX 78778-0001.
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WRITTEN AUTHORIZATION (ADP)

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Completed 8 February 2021

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