Revocation Of Authorization For Third Party Reporting {1841}

Mail To: Office of the Attorney General Employer Services P.O. Box 12017 MC-046 Austin, TX 78711-2017 800-850-6442 www.employer.texasattorneygeneral.gov OAG USE ONLY Date Received: __________ EID: ___________________ Revocation of Authorization for Third Party Reporting This form should be used to revoke the authorization of a Third Party agent to conduct business with the Office of the Attorney General, Child Support Division. Please check the appropriate box, sign, date, and return the form to the address in the upper left corner. I am an authorized representative for the Employer, and request that the Office of the Attorney General, Child Support Division, revoke the authorization which allowed the below named Third Party agent to transact business on the Employer's behalf. I am an authorized representative for the Third Party agent, and request that the Office of the Attorney General, Child Support Division, revoke the authorization which allowed business to be transacted on behalf of the Employer listed below. Employer Name: Employer FEIN: Contact Name and Phone: ___________________________________________ ___________________________________________ ___________________________________________ Third Party Agent Name: Third Party Agent FEIN: Contact Name and Phone: ___________________________________________ ___________________________________________ ___________________________________________ _________________________________________ Printed Name _________________________________________ Signature _________________________________________ Title (Owner, Partner, Officer, etc.) _________________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com January 2014 Manual Form 1841