STATE OF NEW MEXICO                                              
                   DEPARTMENT OF WORKFORCE SOLUTIONS                                          
                                      401 Broadway, NE 
                                      PO Box 1928 
                                 Albuquerque, NM  87103 
                                            
     ELECTION OF EMPLOYER’S OPTION TO BECOME LIABLE FOR 
                   PAYMENTS IN LIEU OF CONTRIBUTIONS 
 
TO: 
New Mexico Department of Workforce Solutions 
PO Box 1928 
Albuquerque, NM  87103 
 
Pursuant to the provisions of Section 51-1-13 NMSA 1978 and Regulation 11.3.400.421, the undersigned, 
an employing unit subject to the said  Act, does hereby elect to make payments in lieu of contributions 
beginning  on  ______________________________,  and  for  a  period  of  not  less  than  two  consecutive 
calendar years. 
 
            Employing Unit is applying under NMSA 1978 Section 51-1-13.  Government entities are not 
      required to send the attachments below: 
                   
                   Completed Online Registration 
                   Copy of the IRS Exemption under Section 501(c)(3) of the IRS Code. 
                   Surety Bond  
 
            Employing Unit is applying under NMSA 1978 Section 51-1-59 Indian Tribes, the employing 
     unit is to attach the following: 
      
                   Completed Online Registration 
 
The undersigned requests written approval by the New Mexico Department of Workforce Solutions of this 
election. 
 
Enter the Taxable Wages paid during the prior four (4) calendar quarters ending June 30.  If no wages were 
paid during the preceding four (4) calendar quarters ending June 30, please estimate the amount to be paid.  
 
1 stQuarter 20_______$____________________       3 rdQuarter 20_______$___________________ 
 
2 ndQuarter 20_______$___________________        4  thQuarter 20_______$___________________ 
 
_____________________________________________           __________________________ 
LEGAL NAME OF EMPLOYER                                  DATE 
 
______________________________________                  ________________________________ 
Prepared by                                             Title 
 
DECLARATION OF VERIFYING OFFICER:  The above person whose signature appears on this document is a duly 
authorized representative of the employing unit, empowered to exercise this option. 
 
The above election commencing as of _________________________, 20________ is        Approved Disapproved 
 
Account No. ________________________  By:_______________________________________________ 
 
Date:___________________              Title:______________________________________________ 
ES-802O, Rev 7.07