<p>WVUC-A-180 Rev. 9-93 WORKFORCE WEST VIRGINIA UNEMPLOYMENT COMPENSATION DIVISION</p><p>BENEFITS REIMBURSEMENT AGREEMENT</p><p>TO: Commissioner Workforce West Virginia Unemployment Compensation Division 112 California Avenue Charleston, West Virginia 25305</p><p>The undersigned employer, having been determined liable for coverage under the</p><p>West Virginia Unemployment Compensation Law, hereby agrees to make payments, on a reimbursement basis in lieu of contributions, to the Division of Unemployment</p><p>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</p><p>State of West Virginia.</p><p>Name of: Nonprofit Organization, Political Subdivision, or Government Entity (Whichever is applicable)</p><p>Address </p><p>By </p><p>Signature of Officer or Authorized Representative</p><p>Title Date</p>