Form Id 1197 - Refund Request Application

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P.O. Box 9046  Olympia, WA 98507-9046
Refund Request Application
Instructions Please see detailed instructions on the next page.
Mail this completed form to:
Employment Security Department
UI Tax & Wage Administration
P.O. Box 9046
Olympia WA 98507-9046
Date requested:
Employer Name and address that you use on tax reports:
1
3
ES reference number:
4
UBI number:
5
Shut-down date:
Phone
Phone number and any extension:
2
6
Refund
Amount of refund requested, including penalties and interest:
7
Reason
Please explain in detail why you should receive a refund:
8
Employer’s signature
Employer’s title
9
10
This claim for refund is provided under RCW 50.24.150 of the Washington Employment Security Act.
ID 1197 (8/22/13) EMS 5227 Refund request - application (to download)

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