Form Uc 336 – Fill Out and Use This PDF

ELECTION BY FAMILY-OWNED CORPORATION TO BE EXCLUDED FROM COVERAGE UNDER

SECTION 383-7(20), HAWAII REVISED STATUTES

Please read the information on the reverse side of this form before electing exclusion from coverage.

1.Complete the following items:

a.Employer’s Account Number ____________________________________________________

b.Employer’s Name ____________________________________________________________

c.Employer’s Address___________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2.Provide in the space below, the name and social security number of all employees of the corporation, percent of shares owned, and how these employees are related. You are also required to submit a copy of the corporation’s Corporate Exhibit.

		% of
Employee’s Name	Social Security #	Shares Owned	Relationship

3.Upon request, you will be required to furnish the department a copy of Form 940, "Employer's Annual Federal Unemployment (FUTA) Tax Return," that you filed with the Internal Revenue Service.

4.The election for exclusion and certification must be signed by all employees of the corporation.

The undersigned elects exclusion from coverage under Section 383-7(20), Hawaii Revised Statutes, and certifies that the information provided herein are true and correct. The undersigned also understands that in accordance with the Federal Unemployment Tax Act (FUTA), the department will provide information to the Internal Revenue Service to insure that FUTA taxes are properly paid.

Signature _____________________________	Signature _____________________________
Print Name ____________________________	Print Name ____________________________
Title__________________________________	Title _________________________________
Date _________________________________	Date _________________________________

Submit this form to your nearest Unemployment Insurance Branch Office.

OAHU: Employer Services Section	HAWAII: 180 Kinoole St., #210 MAUI:	54 S High St., # 201	KAUAI: 3100 Kuhio Hwy C-12
P.O. Box 700	Hilo, HI 96720-2827	Wailuku, HI 96793-2198	Lihue, HI 96766-1153
Honolulu, HI 96809-0700	Ph: 974-4086	Ph: 984-8410	Ph: 274-3025
Ph: 586-8913/586-8914	FAX: (808) 974-4085	FAX: (808) 984-8444	FAX: (808) 274-3046
FAX: (808) 586-8929