Family Corporate Officer Exclusion Request Form
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1
2Family Corporate Officer Exclusion Request
(Note: Exclusion is not in effect until you receive written approval.)
Business name
Business identification number (BIN)
Business address
City
State
Zip Code
Does the business have employees other than the corporate
Today’s date:
q
Yes
officers listed below?
q
No
If this request reflects changes to the ownership or officers since a previous
Date of change:
request, what is the date the change occurred?
Contact name (please print)
Telephone number
(
)
Ext.
Pursuant to ORS 657.044 it is requested that the following owners be exempted from unemployment
insurance. (It is required that 100 percent (%) of the ownership be accounted for.)
Name (please print)
Social Security number
Corporate Title (e.g. President, Secretary, Treasurer)
Director
q
Yes
q
No
Percent (%) ownership
Family relationship
Signature
Date
Name (please print)
Social Security number
Corporate Title (e.g. President, Secretary, Treasurer)
Director
q
Yes
q
No
Percent (%) ownership
Family relationship
Signature
Date
Name (please print)
Social Security number
Corporate Title (e.g. President, Secretary, Treasurer)
Director
q
Yes
q
No
Percent (%) ownership
Family relationship
Signature
Date
Name (please print)
Social Security number
Corporate Title (e.g. President, Secretary, Treasurer)
Director
q
Yes
q
No
Percent (%) ownership
Family relationship
Signature
Date
Please complete as many pages as necessary to attach with your
request if there are more than four officers.
Mail to: WorkSource Employment Department - Tax Section • 875 Union Street NE
• Salem OR 97311-0030 -OR- FAX: (503) 947-1700
IMPORTANT – READ REVERSE SIDE
WorkSource Oregon Employment Department • • Form 2578 (0111) page 1 of 2
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