ELECTION TO REPORT AND PAY UNEMPLOYMENT
              INSURANCE CONTRIBUTIONS
WITH RESPECT TO DOMESTIC SERVICES EMPLOYEES

 PLEASE CHECK ONLY ONE OF THE FOLLOWING:

           ____ Quarterly

           ____ Annually

 An employer who elects to pay contributions annually shall be subject to
 the following terms regarding such contributions:

 (1)          Contributions shall become due and shall be paid by each
              employer on or before January thirty-first with respect to
              wages paid for employment in the previous calendar year.

           (2)Any separation of employment shall be reported within ten
              days of such separation, along with the employer's payroll
              report.

           (3)In the event of a termination of the employer's account,
              contributions shall be due and payable at the next regular
              quarterly due date.

           (4)Any penalties or interest shall be calculated in the same
              manner as those for any other type of employment.

           (5)Any election to pay such contributions annually shall not be
              terminable by the employer for two calendar years.

           (6)In the payment of contributions, a fractional part of a cent
              shall be disregarded unless it amounts to one-half cent or
              more, in which case it shall be increased to one cent.

 NOTE:        Although contributions are paid and wages are reported
              annually, a subtotal of wages paid by quarter is required.

 ___________________________________       _____________________
                Employer Name                                             Account No.

 ___________________________________       _____________________
              Employer Signature                                                Date
 
 Rev(01/09)