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Get Form 68 0463 Iowa Workforce Development

501 c 3 Election or Change of Status 68-0463 03-12 Unemployment Insurance Tax Bureau 1000 E Grand Ave Des Moines IA 50319 Phone 888-848-7442 option 3 then option 7 This form is for a 501 c 3 non-profit employer covered under Iowa Code section 96. 19-16i to request or terminate an election to make payments in lieu of contributions Reimbursable Status. R Check the option you are requesting Request Reimbursable Status - You agree to reimburse Iowa Workforce Development for benefits paid for regular benefits and one-half of extended benefits. 501 c 3 Election or Change of Status 68-0463 03-12 Unemployment Insurance Tax Bureau 1000 E Grand Ave Des Moines IA 50319 Phone 888-848-7442 option 3 then option 7 This form is for a 501 c 3 non-profit employer covered under Iowa Code section 96. 19-16i to request or terminate an election to make payments in lieu of contributions Reimbursable Status. R Check the option you are requesting Request Reimbursable Status - You agree to reimburse Iowa Workforce Development for benefits paid for regular benefits and one-half of extended benefits. - You must remain a reimbursable employer for at least two consecutive calendar years. - At the end of each quarter you will be billed for any benefits charged to your account during the quarter. - Payments are due within 30 days after the quarterly statement was mailed* Request to Terminate Reimbursable Status - You must have been a reimbursable employer for at least two consecutive calendar years. - All of your payments and reports must be current. Note All requests must be received by December 1st. If approved your change in status will be effective on January 1st of the following year. UI Account Legal Business Name DBA Address 1 City FEIN State/Province Zip 4/Postal Code By signing below you agree to the terms above. Date Authorized Signature Print Name Return signed form to Iowa Workforce Development Title Agency Approval UI Representative Approval Date Equal Opportunity Employer/Program Auxiliary aids services are available upon request to individuals with disabilities. 501 c 3 Election or Change of Status 68-0463 03-12 Unemployment Insurance Tax Bureau 1000 E Grand Ave Des Moines IA 50319 Phone 888-848-7442 option 3 then option 7 This form is for a 501 c 3 non-profit employer covered under Iowa Code section 96. 19-16i to request or terminate an election to make payments in lieu of contributions Reimbursable Status. 19-16i to request or terminate an election to make payments in lieu of contributions Reimbursable Status. R Check the option you are requesting Request Reimbursable Status - You agree to reimburse Iowa Workforce Development for benefits paid for regular benefits and one-half of extended benefits. R Check the option you are requesting Request Reimbursable Status - You agree to reimburse Iowa Workforce Development for benefits paid for regular benefits and one-half of extended benefits. - You must remain a reimbursable employer for at least two consecutive calendar years. - At the end of each quarter you will be billed for any benefits charged to your account during the quarter.

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