Workforce West Virginia

WVUC-A-180 Rev. 9-93 WORKFORCE WEST VIRGINIA UNEMPLOYMENT COMPENSATION DIVISION

BENEFITS REIMBURSEMENT AGREEMENT

TO: Commissioner Workforce West Virginia Unemployment Compensation Division 112 California Avenue Charleston, West Virginia 25305

The undersigned employer, having been determined liable for coverage under the

West Virginia Unemployment Compensation Law, hereby agrees to make payments, on a reimbursement basis in lieu of contributions, to the Division of Unemployment

Compensation in the manner and amounts provided for under Chapter 21A-5-3a or 21A-5-3b, whichever is applicable to the Unemployment Compensation Law, referring to financing benefits paid to employees of nonprofit organizations and/or employees of political subdivisions and/or employees of government entities of the

State of West Virginia.

Name of: Nonprofit Organization, Political Subdivision, or Government Entity (Whichever is applicable)

Address

Signature of Officer or Authorized Representative

Title Date