Authorized Representative Designation I, Name (principal) Address of Name of authorized representative Phone Address as my authorized representative. Family Group Number (FGN) residing at hereby appoint My authorized representative has power and authority to communicate on my behalf with Child Support Services (CSS) about the child support case above to the extent allowed by this designation. I agree to hold CSS harmless for actions taken in reliance on this document. My authorized representative shall have the power to get or give information and documents. This designation does NOT allow my authorized representative to appear in district or administrative court for me or sign documents on my behalf. My authorized representative can be held responsible for intentional wrongdoing or for failing to represent me in good faith. I understand CSS can revoke this designation for misconduct. I understand I may have only one authorized representative at a time who cannot be a person that would create a conflict of interest in another of my cases. This designation is effective immediately, and is not affected by my disability or lack of mental competence, unless this conflicts with state law. This designation is effective until my death, unless I revoke it in writing or submit a new Form 03EN010E, Authorized Representative Designation. This designation can be revoked by me at any time. Signature Principal signature Date **** This completed document must be returned with a copy of your photo ID to your local child support office BEFORE anyone from CSS is able to speak with your authorized representative about your case. Once received, it will remain in effect until CSS is notified IN WRITING of its revocation, until CSS receives a new Authorized Representative Designation designating another individual as the authorized representative, or is revoked by CSS for misconduct. Form 03EN010E 11/1/2016 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1