Notice Of Election By Nonprofit Organization Form - Ohio Bureau Of Employment Services
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1OHIO BUREAU OF EMPLOYMENT SERVICES
145 South Front St., P.O. Box 923
Columbus, Ohio 43216-0923
NOTICE OF ELECTION BY NONPROFIT ORGANIZATION
Name of Organization
FOR BUREAU USE ONLY
Initial Liability Account Number
Street Address
Reimbursing Account Number
City, State, ZIP Code
1.
attached, Resolution of governing body authorizing this election
Submitted previously.
2.
attached, Letter of exemption from Internal Revenue Service
Submitted previously.
3.
attached, Copy of Corporate Charter or other
Submitted previously.
4.
Payroll for the last four completed calendar quarters:
(a) Total covered wages for quarter ending
$
(b) Total covered wages for quarter ending
$
(c)
Total covered wages for quarter ending
$
(d) Total covered wages for quarter ending
$
(e) Total covered wages for last four completed quarters
$
5.
An employer electing reimbursing status must be bonded to the extent of three percent of the total wages as
shown in item 4(e), (maximum $2,000,000). It is hereby agreed that such bonding requirement will be met.
Date
Signature and title of authorized official
FOR BUREAU USE ONLY
Bonding Amount
Accepted
YES
NO
$
Effective date
Date
By
CDF-690 (R 9-97)
BES 0569
68
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