STATE OF GEORGIA - DEPARTMENT OF LABOR 148 Andrew Young International Blvd., N.E., Suite 850 Atlanta, Georgia 30303-1751 Phone (404) 232-3301 (Do not write in this space.) Georgia DOL Account No. _______________________ Approved: ___________ Yes _________ No ________ By: ________________ Effective Date _____________ Date Mailed to Employer ________________________ EMPLOYEE LEASING COMPANY ELECTION TO REPORT LEASED EMPLOYEES Type or print answers in ink and return both copies to the above address. A copy of the application will be returned to you advising the action taken by the Department. 1. _________________________________________________________________________________________________ Business Name 2. _________________________________________________________________________________________________ Business Address 3. _________________________________________________________________________________________________ Mailing Address (If different) 4. Requested Effective Date: ___________________________________________________________________________ The undersigned does hereby voluntarily elect to report and otherwise treat all leased employees as its own employees for all purposes of unemployment insurance under the Georgia Employment Security Law and to post the surety bond, cash or securities as specified in the attached form DOL-12B. By making this election, the undersigned acknowledges it has carefully read and will comply with all applicable rules or regulations of the State of Georgia which pertain to employee leasing. Enter Taxable Wages paid during the preceding four (4) calendar quarters. (Taxable wages: line 4 Employer's Quarterly Tax and Wage Report) Qtr. _________ Yr. _________ $ _______________________ Qtr. ________ Yr. _________ $ _______________________ Total for Year $ _______________________ Qtr. _________ Yr. _________ $ _______________________ Qtr. ________ Yr. _________ $ _______________________ If in business less than one (1) year, indicate date employment of leased workers began: _____________________________ Firm Name _________________________________________________________________________________________ By ________________________________________________________________________________________________ Title _______________________________________________________________________________________________ To Be Completed by Georgia Department of Labor Date _______________________________________________________________________________________________ Pursuant to OCGA Section 34-8-172 of the Employment Security Law, you are hereby notified that you are required, within thirty days from _______________________________________________________________________ , to execute and file with (Date Approved) the Commissioner of Labor a cash deposit or surety bond in the amount of $ ______________________ . This same section permits you, in lieu of either the cash deposit or surety bond, to deposit with the Commissioner of Labor acceptable securities in the amount of $ ___________________ . You are required, within thirty days from ______________________________________________, to complete the attached "Employee Leasing Company's Election of Cash Deposit, Surety Bond or Securities" form and return it to this Department. The above election is hereby: Approved Effective ___________________________________________________________________________________ Disapproved for the following reasons: ______________________________________________________________________ ______________________________________________________________________________________________________ ___________________________________________________________________________________________________ Commissioner of Labor By ___________________________________________ UI Adjudication American LegalNet, Inc. www.FormsWorkFlow.com DOL-11B (R-04/14) (Current Date)