Form Lb-0443 - Report To Determine Status State And Local Government Page 2

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ELECTION TO BECOME A REIMBURSING EMPLOYER
Federal No. ___ ___ - ___ ___ ___ ___ ___ ___ ___
Date _________________
Pursuant to the provisions of Section 50-7-403(h) of the Tennessee Employment Security Law, the undersigned eligible
employer elects to reimburse the Tennessee Department of Labor and Workforce Development for all unemployment insurance
benefits (including the amount of extended benefits) charged to this legal entity during the effective period of election.
This employer elects to reimburse the Department of Labor and Workforce Development for benefits charged by one of the
two methods indicated below:
1. The Department shall bill the employer on a monthly basis for the full amount of regular benefits plus one-half of
extended benefits paid attributable to service in the employ of the employer. The employer shall make full
payment of the billed amount within thirty (30) days from the date the bill was mailed to the employer, unless the
employer has filed an application for a review and redetermination of such bill. If an application for a review and
redetermination has been filed, the employer must pay the bill in full within fifteen (15) days of the final
determination of this issue by the Department of Labor and Workforce Development.
or
2. The employer shall on a quarterly basis pay a percentage of its total payroll for the immediately preceding
calendar year. The percentage will be determined by the Department based on the employer’s average
unemployment benefit cost during the preceding calendar year. (The Department will determine the percentage
if the employer did not pay wages in the preceding calendar year.) At the end of the calendar year, the Department
will determine whether the total payments are less than or in excess of benefits chargeable to the employer
during the calendar year. If the payments are insufficient, the employer will be billed for the unpaid balance. If
the payments are in excess of benefit charges, the Department may, at its discretion, refund all or part of the
excess or may retain all or part as payment against charges expected to be incurred in the next calendar year.
This agreement is effective for a minimum of one complete taxable year. Any request to terminate this agreement and
become a premium-paying employer must be filed in writing with the administrator of the Employment Security Division
within thirty (30) days prior to the end of the then current taxable year. (All taxable years end on June 30th.)
Agency __________________________________
By ______________________________________
Title _____________________________________
LB-0443 (Rev. 02-15)
Page 2
RDA 1559

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