MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 
                                            APPLICATION FOR TERMINATION OF COVERAGE 
                                            
                                            COMPLETE AND RETURN TO: 
                      Liability Unit, Division of Employment Security, P.O. Box 59, Jefferson City, MO 65104-0059 
                                                                                                        
   Business Name:                                                           Account Number:            
                                                                            Federal ID Number:            
               Address:                                                                                 
                                                                                                        
In order to terminate your liability as an employer subject to the Missouri Employment Security Law 
effective January 1 of any calendar year, your written application for termination of coverage must be 
filed with this Division no later than February 10 of the year with respect to which the termination is to 
be effective. 
Termination to be effective January 1,               . 
      1.   General Employment – In the preceding calendar year there must have been less than 20 weeks in which you employed one or 
           more workers for some portion of a day in employment covered by the law, and no calendar quarter in which you paid wages 
           of $1,500.00 or more. 
        Enter the number of calendar weeks in the preceding calendar year in which you employed one or more 
        workers for some portion of a day.                       Weeks 
           Record total wages paid in each calendar quarter in the preceding calendar year. 
           1st Qtr.                        2nd Qtr.                         3rd Qtr.                           4th Qtr.             
                      (Jan 1 thru Mar 31)            (Apr 1 thru Jun 30)              (Jul 1 thru Sep 30)                (Oct 1 thru Dec 31) 
      2.   Domestic Employment – In the preceding calendar year there must be no calendar quarter in which you paid domestic wages 
           of $1,000.00 or more. 
        Record total wages paid in each calendar quarter in the preceding calendar year. 
           1st Qtr.                        2nd Qtr.                         3rd Qtr.                           4th Qtr.             
                      (Jan 1 thru Mar 31)            (Apr 1 thru Jun 30)              (Jul 1 thru Sep 30)                (Oct 1 thru Dec 31) 
      3.   Agricultural Employment – In the preceding calendar year there must have been less than 20 weeks in which you employed 10 
           or more workers for some portion of a day in employment covered by the law, and no calendar quarter in which you paid 
           wages of $20,000.00 or more. 
        Enter the number of calendar weeks in the preceding calendar year in which you employed 10 or more 
        workers for some portion of a day.                       Weeks 
           Record total wages paid in each calendar quarter in the preceding calendar year. 
           1st Qtr.                        2nd Qtr.                         3rd Qtr.                           4th Qtr.             
                      (Jan 1 thru Mar 31)            (Apr 1 thru Jun 30)              (Jul 1 thru Sep 30)                (Oct 1 thru Dec 31) 
      4.   501(c)(3) Entity – In the preceding calendar year there must have been less than 20 weeks in which you employed four or 
           more workers for some portion of a day in employment covered by the law. 
        Enter the number of calendar weeks in the preceding calendar year in which you employed four or more 
        workers for some portion of a day.                       Weeks 
 
 I certify that the statements herein contained are true and correct: 
                                                                                                                     
Signature                                                                                                 Date 
                                                                                                                     
Title                                                                                                     Phone 
   
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