EMPLOYER'S STATEMENT FOR THE PURPOSE OF TERMINATING STATUS AS A COVERED EMPLOYER 1.EMPLOYER'S NAME EMPLOYER'S ADDRESS CITY, STATE and ZIP CODE 2.EMPLOYER'S FEIN 3.BUSINESS or TRADE NAME, if different from above4.The above-named EMPLOYER, in accordance with Section 202 of the Disability and Paid Family Leave Benefits Law,makes the following statements for the purpose of terminating his or her status as a covered employer.a.The latest calendar year during which one or more employees were employed on each of at least thirty days wasthe calendar year which ended DECEMBER 31,b.There were not one or more employees in employment for thirty or more days during the calendar year whichended DECEMBER 31,c.Employees were required to contribute toward the cost of providing disability benefits Employees were required to contribute toward the cost of providing paid family leave benefitsd.The amount of excess employee contributions on this date is $(Enter "None" if there are no excess excess employee contributions)I certify to the best of my knowledge the foregoing statements are complete and true. Yes No Yes No Date Signed Signature of Owner, Partner or Authorized Officer if a Corporation Telephone Number Title FOR BOARD USE ONLY To the above-named EMPLOYER: Satisfactory evidence having been filed, your status as a covered employer is terminated as ofDB-118 (10-17) SEE IMPORTANT NOTICE ON REVERSE Disability and Paid Family Leave Benefits Coverage Section DateByDISABILITY AND PAID FAMILY LEAVE BENEFITS LAW American LegalNet, Inc. www.FormsWorkFlow.com PROVISION OF DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PERTAINING TO DEFINITION OF EMPLOYEE SEC. 201. specifies that "Employee means a person engaged in the service of an employer in any employment defined in subdivision six of this section, except a minor child of the employer, except a domestic or personal worker in a private home who is employed for less than forty hours per week by any one employer, and except a duly ordained, commissioned, or licensed minister, priest or rabbi, a sexton, a Christian Science reader, or member of a religious order, or an executive officer of a corporation who at all times during the period involved owns all of the issued and outstanding stock of the corporation and holds all of the offices pursuant to paragraph (e) of section seven hundred fifteen of the business corporation law or two executive officers of a corporation who at all times during the period involved between them own all of the issued and outstanding stock of such corporation and holds all such offices provided, however, that each officer must own at least one share of stock, except as provided in section two hundred twelve of this article, or persons engaged in a professional or teaching capacity in or for a religious, charitable or educational institution, or volunteers in or for a religious, charitable or educational institution, or persons participating in and receiving rehabilitative services in a sheltered workshop operated by a religious, charitable or educational institution under a certificate issued by the United States department of labor, or recipients of charitable aid from a religious or charitable institution who perform work in or for the institution which is incidental to or in return for the aid conferred and not under an express contract of hire. The terms "religious, charitable or educational institution" mean a corporation, unincorporated association, community chest, fund or foundation organized and operated exclusively for religious, charitable or educational purposes, no part of the net earnings of which inure to the benefit of any private shareholder or individual. PROVISION OF DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PERTAINING TO TERMINATION OF COVERAGE SEC. 202. provides that a covered employer, shall continue to be a covered employer until the end of any calendar year in which he shall not have employed in employment one or more employees on each of thirty days, and shall have duly filed with the chairman satisfactory evidence thereof. A covered employer of employees in personal or domestic service in a private home shall continue to be a covered employer until the end of any calendar year in which he shall not have employed in such service one or more employees for at least forty hours per week and on each of at least thirty days, and shall have duly filed with the chairman satisfactory evidence thereof. SEC. 216. specifies that when an employer shall cease to be a covered employer all employee contributions in excess of those utilized to pay accrued benefits and to provide benefits under the law may be used for the benefit of employees on a reasonable basis approved by the chairman and any such sums not so used shall be promptly paid to the chairman for deposit in the fund created under Sec. 214. SEC. 220. provides that any person who knowingly makes a false statement for the purpose of influencing any determination under the Law or fails to disclose a material fact, shall be guilty of a misdemeanor.DB-118 (10-17) REVERSE COMPLETE FORM DB-118 AND MAIL TO: WORKERS' COMPENSATION BOARD BUREAU OF COMPLIANCE PO BOX 5200 BINGHAMTON, NY 13902-5200 American LegalNet, Inc. www.FormsWorkFlow.com