Mail To: 
Cashier - Texas Workforce Commission 
P.O. Box 149037 
Austin, TX 78714-9037 
512.463.2731 
www.texasworkforce.org 
 
                                     TEXAS WORKFORCE COMMISSION 
                                      ELECTION TO PAY REIMBURSEMENTS 
                                                                                                                 
                                                                                                   Account Number 
 
1. Name of organization making          
   this election:                                 
                                        
2. Mailing Address:                     
                                                  
                                       Street 
                                        
                                       City                                               State      Zip Code 
 
3. The above named employing unit hereby elects to pay reimbursements for benefits paid to its former 
   employees in lieu of paying contributions (taxes) under the law.  
 
4. It is understood and agreed that a surety bond and/or adjusted surety bonds will be promptly executed and 
   filed with the Commission when this organization is directed to do so by the Commission. 
 
5.  The effective date of this election is the first day of January,          (Year) and shall be for a minimum period 
   of two (2) calendar years. It is understood and agreed that this election cannot be terminated prior to that 
   time except that the Commission may terminate this election as of the beginning of the next taxable year if 
   the organization is delinquent in making reimbursements or if it fails to make a surety bond when directed 
   to do so by the Commission.  It is also understood and agreed that this election may be withdrawn by the 
   organization by filing a written application with the Commission no later than December 1 prior to the 
   beginning of the year with respect to which the organization wishes to change its method of payment. 
 
                                                          Date:                           
             This election must be signed by a duly                              
             authorized official of the organization      Signed by:                                  
             making                   this   election.      
                                                                                
                                                          Title:                          
 
This application approved by the Texas Workforce Commission on              
 
             This       application                      will              be effective                                                only when 
             it is approved by the Commission.                                                 Tax Department 
                                                                                TEXAS WORKFORCE COMMISSION 
 
                        Individuals may receive, review and correct information that TWC collects  
                        about the individual by emailing to open.records@twc.state.tx.us or writing  
                                                      th
                        to TWC Open Records, 101 E. 15  St., Rm. 266, Austin, TX  78778-0001. 
                                                         
Form C-6A (052013)