Emsx 5200-99 Request For Unemployment Insurance Tax Payment Method Form

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REQUEST FOR UNEMPLOYMENT INSURANCE
TAX PAYMENT METHOD
Name:
ES Reference No.
Mailing Address:
UBI Number
Business Phone:
(
)
NOTE: All Corporate Officers are reportable regardless of which payment option you choose.
I. NON-PROFIT ORGANIZATIONS -
Attach a copy of the Certificate of Exemption under
Section 501(C)(3) of the Internal Revenue Code.
Check A or B to select method of unemployment insurance payments:
A. Quarterly wage reports with quarterly payment of tax due.
B. Payments in lieu of tax in an amount each quarter equal to the amount of benefits paid to
former workers during the preceding quarter. (Reimbursable)
II. POLITICAL SUBDIVISIONS - Is political subdivision or instrumentality a city, county, or town?
Yes
No
If “Yes” complete A only. If “No” complete B only.
A. Cities, Counties, and Towns only.
Check one to select method of unemployment insurance payments:
Local Government Tax.
Quarterly payments in lieu of tax in an amount each quarter equal to the amount of benefits paid to
former workers during the preceding quarter. (Reimbursable)
B. All other Political Subdivisions or Instrumentalities of the state.
Check one to select method of unemployment insurance payments:
Quarterly wage reports with quarterly payment of tax due.
Quarterly payments in lieu of tax in an amount each quarter equal to the amount of benefits paid to
former workers during the preceding quarter. (Reimbursable)
CERTIFICATE: The statements provided above are hereby certified to be correct to the best knowledge and
belief of the undersigned:
Signed by: ______________________________ Title:
Date:
To file your tax reports and/or to pay electronically go to
(Please See Explanation on Next Page)
EMSX 5200-99 Rev 11/05

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