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 By: Effective Date Date Mailed to Employer No REIMBURSABLE EMPLOYER'S ELECTION OF CASH DEPOSIT, SURETY BOND OR SECURITIES 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. 2. 3. 4. Owner(s) (Legal Entity) Business Name Business Address Mailing Address BasedonmyElectiontoReimbursetheGeorgiaDepartmentofLaborforbenefitspaidinlieuofcontributions,approved , I hereby make the following Election: (Date Approved) Check appropriate block below and comply with instructions. Cash Deposit $ (CertifiedfundsonlymustaccompanythisElection.) Surety Bond $ (A properly executed surety bond, for a minimum of two complete calendar years, from a bonding company licensed to do business in Georgia must accompany this Election.) Securities $ (A list of acceptable securities is on the reverse side of this form. Acceptable securities, in the above amount, along with a properly executed Power of Attorney [forms attached] must be deposited in a State or National chartered bank for safekeeping. Receipt for deposit of these securities and the original of this Power of Attorney must accompany this Election.) Firm Name By Title Date The above election is hereby: Approved Effective Disapproved for the following reasons: (Legal Entity) Mark Butler By Commissioner UI Adjudication DOL-12 (R-4-14) American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to the provisions of Paragraph (b) (5) of O.C.G.A. Section 34-8-160 of the Employment Security Law: The standard of acceptance of securities for deposit, as required by law, shall be the same as that required of personal representatives under Georgia law for investment in bonds and other securities as set forth in O.C.G.A. Section 53-8-3. Such securities shall include, but are not limited to, the following: (a) (b) (c) (d) bonds or other securities authorized by or issued by this State; direct and general obligations of the U. S. Government; obligations unconditionally guaranteed by the U. S. Government; obligations of Agencies of the U. S. Government issued by the: 1. 2. 3. 4. Federal Land Bank; Federal Home Loan Bank; Federal Intermediate Credit Bank; Central Bank for Cooperatives. (e) deposits of funds at interest in any chartered State or National Bank or Trust Company, located in this State, and which are insured by the Federal Deposit Insurance Corporation to the extent of the insurance; (f) accountsandcertificatesofStatecharteredassociationsandFederalsavingsandloanassociations, which are insured by the Federal Savings and Loan Insurance Corporation to the extent of the insurance. American LegalNet, Inc. www.FormsWorkFlow.com