Form Uc-336 - Election By Family-Owned Corporation To Be Excluded From Coverage Under Section 383-7(20), Hrs

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Form UC-336
STATE OF HAWAII
(Rev. 9/93)
Department of Labor and Industrial Relations
Unemployment Insurance Division
ELECTION BY FAMILY-OWNED CORPORATION
TO BE EXCLUDED FROM COVERAGE UNDER SECTION 383-7(20), HRS
Please read the important information on the following page before electing exclusion from coverage.
1.
Complete the following items:
a.
Employer Account Number: __________________________________________________________
b.
Employer Name
__________________________________________________________
c.
Employer Address
__________________________________________________________
__________________________________________________________
__________________________________________________________
2.
Provide in the space below, the name and social security number of all employees of the corporation, percent
of shares owned, and how these employees are related:
Employee Name
Social Security #
% of Shares Owned
Relationship
3.
Upon request, you will be required to furnish the department a copy of Form 940, "Employer's Annual Federal
Unemployment (FUTA) Tax Return" that you filed with the Internal Revenue Service.
4.
The election for exclusion and certification must be signed by all employees of the corporation.
The undersigned elects exclusion from coverage under Section 383-7(2), Hawaii Revised Statutes and certifies that the
information provided herein are true and correct. The undersigned also understands that in accordance with the
Federal Unemployment Tax Act (FUTA), the department will provide information to the Internal Revenue Service to
insure that FUTA taxes are properly paid.
Signature:
______________________________
Signature:
________________________________
Print Name:
______________________________
Print Name:
________________________________
Title:
______________________________
Title:
________________________________
Date:
______________________________
Date:
________________________________
Submit this form to your nearest Unemployment Insurance Branch Office:
Oahu
Hawaii
Maui
Kauai
PO Box 700
777 Kilauea Ave # 122
54 S. High St # 201
3100 Kuhio Hwy # C-12
Honolulu, HI 96809
Hilo, HI 96720
Wailuku, HI 96793
Lihue, HI 96766
Ph: (808) 586-8913
Ph: (808) 974-4086
Ph: (808) 984-8410
(808) 274-3025
FAX: (808) 586-8929
FAX: (808) 974-4085
FAX: (808) 984-8444
FAX: (808) 274-3028

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