Form Fx-2 - Application Form For Voluntary Election
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1
2APPLICATION FOR VOLUNTARY ELECTION
(See Instructions on Reverse Side)
MAINE DEPARTMENT OF LABOR
Bureau of Unemployment Compensation
Central Registration Unit
P.O. Box 259
Augusta. Maine 04332-0259
5. Please provide us with the following information if you are a nonprofit employer:
a) Copy of your By-laws and/or Charter, IRS nonprofit determination letter and funding documents.
b) How do you obtain your operating funds? Please be specific
6. Indicate in each of the following
squares (representing
the weeks of the current and preceding years) the highest daily employment
within
each week.
Include all part-time
workers and corporate officers.
Year
I Week
#
1121314151
61
~1~I~L1o11111211311411511!I~l1811912or211-22123124125126
I Preceding
Year
I Week
#
RI-28129
j 30 131 j 321 3313413511!1]7138139140
141142(43144145'
46147148149150151~52
Week #
1 \ 2
3
41516171
slgl10j
1-~I~jJ:;!!-t)4115~
1611711S119Iio,21f22~23124125126
Current Year
Week #
271281
291-~1~1321
331341351361371
381~1-40
1 411421431441451461471481491501-s1152
7. Enter TOTAL amount of gross wages paid each quarter of the two calendar years in item #6.
8. The undersigned, an employing
unit under the Employment
Security Law, which has not met liability
levels of employment,
voluntarily
elects under Section 1222,3,A to become a subject employer to provide unemployment
insurance coverage for its
employees
effective
January 1,
, and to continue to be subject to the Employment
Security Law for not less than two calendar
years.
Dated this-day
of
20
Name
Signature
Title
FINDINGS BY THE MAINE DEPARTMENT OF LABOR: Your application for Voluntary Election of Coverage is:
[ ] APPROVED
[
DENIED
Augusta,
Maine
(date)
Signed
Unemployment
Compensation
Director
Me. FX-2 (rev. 01/2000)
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