Form Me. Fx-2 - Application For Voluntary Election - 2011
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2Maine Department of Labor
Bureau of Unemployment Compensation, Tax Division
45 Commerce Drive, 47S State House Station
Augusta, ME 04333-0047
APPLICATION FOR VOLUNTARY ELECTION
Business Name (if sole proprietorship, provide name of sole
Date Business Started in Maine:
proprietor):
Address (Street, Number, City or Town, State, and Zip Code):
Describe Business Operated:
A. Please fill out (type or print) this Application for Voluntary Election in black or blue ink. This application should
be prepared in duplicate. Mail the original to the address above and retain the other copy for your records. If
you need assistance in completing the form, please contact a Status or Field Representative at the telephone
number on the reverse.
B. Effective date of voluntary election status must be January 1 of the year coverage is to commence.
C. This Application for Voluntary Coverage must be signed by a person with the authority to sign formal
documents for the business.
D. If you are a nonprofit employer, please provide us with the following information:
a). A copy of your By-laws and/or Charter, IRS nonprofit determination letter, and funding documents.
b). A short description of how you obtain your operating funds. Please be specific:______________________
_____________________________________________________________________________________
E. Indicate in each of the following squares (representing the weeks of the current and preceding years) the
highest daily employment within each week. Include all part-time workers and corporate officers:
Preceding
Week #
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Year
20______
Week #
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Current
Week #
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Year
20_____
Week #
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
F. Enter the TOTAL amount of gross wages paid each quarter of the two calendar years in the item above.
Calendar Quarter
Calendar Quarter
Calendar Quarter
Calendar Quarter
Maine Payrolls
Ending March 31
Ending June 30
Ending September 30
Ending December 31
Preceding Year 20__
Current Year 20__
Me. FX-2 (rev. 06/2011)
Continued on Reverse > >
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