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Form Lb-0962 - Electronic Filing Agreement Form - State Of Tennessee Department Of Labor And Workforce Development

STATE OF TENNESSEE

DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

DIVISION OF EMPLOYMENT SECURITY

EMPLOYER ACCOUNTS OPERATIONS

220 FRENCH LANDING DRIVE

NASHVILLE, TENNESSEE 37243

FAX 615-741-7214

ELECTRONIC FILING AGREEMENT

Employer Name: ____________________________________________________________________________

State UI Account Number: ______________________

Federal EIN: ____________________________

Contact Person: ______________________________

Telephone Number: ______________________

E-mail Address: ___________________________________

Fax Number: ___________________________

This is an agreement between the Tennessee Department of Labor and Workforce Development (hereinafter

“TDLWD”) and _______________________________________________________ (hereinafter “the

Employer”), entered into this on this the ___________ day of ___________________, ________ pursuant to

the provisions of TCA §50-7-404, Rule 0560-2-1 et. seq.

TDLWD and the Employer agree as follows:

1. The TDLWD authorizes the Employer to file the quarterly premium and wage reports required by the above provisions

by means of transmission of data by modem to the Department’s Bulletin Board System.

2. The signature on this Agreement shall be deemed to appear on any transmission received by TDLWD’s Bulletin Board

System.

3. This Agreement constitutes electronic filing which satisfies the law requiring an employer or employer’s agent reporting

250 or more employees to file wage items by magnetic media. This agreement does not change or substitute for any

other legal requirements, including due dates.

4. This Agreement will be effective beginning _________________ quarter/year.

Employer or Agent

Signature _________________________________

Telephone Number ___________________

Employer or Agent

TDLWD Official

Name Printed

_____________________________

Signature ___________________________

Title _____________________________________

Title _______________________________

Date _________________

LB-0962 (Rev. 04-08)

Form Lb-0962 - Electronic Filing Agreement Form - State Of Tennessee Department Of Labor And Workforce Development