UCT-17927-E, Reelection of Coverage of Principal Officers



Department of Workforce Development

Unemployment Insurance Division

Employer Service Team

P.O. Box 7942

Madison, WI 53707

Telephone: (608) 261-6700

Fax: (608) 267-1400

Email: taxnet@dwd.

REELECTION OF COVERAGE OF PRINCIPAL OFFICERS UNDER

WISCONSIN'S UNEMPLOYMENT INSURANCE ACT

Wisconsin State Statutes 108.025

To be effective for a calendar year, an employer shall file a notice of reelection no later than March 31 of that year. The corporation will receive an Initial Determination advising the status of this election.

The following named corporation:

|Business Name |WI UI Account Number |

|      |      |

Reelects, effective as of January 1,       coverage under Wisconsin's Unemployment Insurance law all of its principal officers listed below, i.e. president, vice-president(s), secretary and treasurer.

|Principal Officer Name |% Ownership |Title in Corporation or LLC |SSN |

| | | | |

|      |      |      |      |

| | | | |

|      |      |      |      |

| | | | |

|      |      |      |      |

| | | | |

|      |      |      |      |

The undersigned certifies that:

• They are a corporate officer with authority to act on behalf of the corporation.

• It is understood that an employer reelecting coverage of its principal officers is not eligible to again file an election to exclude principal officers under Wisconsin's Unemployment Insurance Act.

|Corporate Officer Name |Telephone Number |

|      |      |

|Corporate Officer Signature |Date Signed |

| |      |

|Email Address |

|      |

-----------------------

REELECTION OF COVERAGE

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download