Form Me. Fx-3 - Application For Termination Of Coverage Form - Maine Department Of Labor
ADVERTISEMENT
1
2MAINE DEPARTMENT OF LABOR
Bureau
of
Unemployment
Compensation
20 Union
Street,
P.
0.
Box 259
Augusta,
Maine
04332-0259
(207)
287-3176
APPLICATION
FOR
TERMINATION
OF
COVERAGE
In
Item
4
enter
the
total
amount
of
reportable
wages
(see
exclusions
below)
paid
each
quarter
of
the
preceding
calendar
year.
In
item
5 enter
in
each
applicable
block
the
greatest
number
of
individuals,
both
full
and
part-time
workers,
who
were
employed
by
you
in
Maine
on
the
day
of
the
highest
employment
in
each
week,
for
the
preceding
calendar
year.
If
a corporation,
include
all
your
officers
who
are
performing
services
as well
as all
other
workers.
EXCLUSIONS:
All
EmDlovers:
Do
not
include
services
performed
by
a student
who
is
participating
in
a cooperative
program
of
education
and
occupational
training.
If
a proprietorshi12,
do
not
include
the
service
performed
byan
individual
in
the
employ
of
his
son,
daughter,
spouse,
or
the
service
performed
bya
child
under
18
in
the
employ
of
his
father
or
mother.
Do
not
include
partners
in
a ~artnershi~.
DOMESTIC
EMPLOYERS
MAY
SKIP
THIS
QUESTION:
Do
you
have
a controlling
interest
in
another
business
with
Maine
employment,
or
are
you
controlled
by
the
controlling
interests
of
another
business
with
Maine
emplo:r::.
ment?
If
so,
list
the
other
Maine
Employer
Account
Number(s)
: IF
NOT,
CHECK
HERE
U
4.
III.
AGRICULTURAL
EMPLOYMENT
5.
Year
1213141516
I 718191101111121131-141-1511611711~I~l2012l122123124125-I
19
-281
2913°131
'32133
I
34135136
, ~713~
j
39140141-14il43144145146JRl48149150
151
152153
111* REGULAR
EMPLOYMENT
The undersigned
hereby affirms
that the information
given above is true and correct,
and hereby makes application
for
termination
of
coverage
as an employer
under the Maine
Employment
Security
Law,
such termination
to be
effective
as of January I. 19-.
ISigned
Title
Date
ield
Advisor
and
Examiner
Date
DENIED
(See
letter
Augusta, Maine (date)
Signed
, u.
c.
Director
Me. FX-3
(rev. 04/99)
INSTRUCTIONS
ON REVER~
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