Mail To:                                                                  
Cashier - Texas Workforce Commission 
P.O. Box 149037 
Austin, TX 78714-9037                                                    Account Number                  
512.463.2731 
www.texasworkforce.org                                                   Employer            
 
                         APPLICATION FOR TERMINATION OF COVERAGE 
  SECTION 1: GENERAL INFORMATION 
  1.  NOTICE: Termination of an employer’s coverage voids all previous compensation experience for the purpose of  
      determining experience tax rates. 
  2.  SECTION 206.004 of the TEXAS UNEMPLOYMENT COMPENSATION ACT 
      a.   An employing unit may cease to be an employer only on January 1 of a year and only if the Commission 
             finds that: 
             1) the employing unit was not an employer during the preceding year; or 
             2) the employing unit has not had any individuals in employment during the preceding three calendar years. 
      b.     The Commission may not make a finding under Section (a)(1) unless the employing unit files an application for  
             termination of coverage with the Commission on or after January 1 but before April 1 of the year         
      for which termination is requested. The Commission may make a finding under Subsection (a)(2)    
      without an application having been filed. 
  3.  SECTION 206.005 of the TEXAS UNEMPLOYMENT COMPENSATION ACT 
        When an employing unit that ceased to be an employer subsequently becomes an employer, the employing  
      unit is considered to be a new employer without regard to the rights that employing unit acquired when previously  
      an employer. 
   
  SECTION 2: DOMESTIC EMPLOYMENT 
   
  1.     Enter the amount of cash wages paid for DOMESTIC employment during each calendar quarter of the year 
         preceding January 1 of the termination year. 
   
             Jan-Mar $                 Apr-June $                    July-Sept $           Oct-Dec $             
   
  SECTION 3: FARM AND RANCH EMPLOYMENT 
   
  1.  Enter the amount of wages paid for FARM AND RANCH employment during each calendar quarter of the year                   
     preceding January 1 of the termination year: 
   
         Jan-Mar $                   Apr-June $                    July-Sept $             Oct-Dec $             
   
  2  During the preceding year, did you employ at least three persons in Texas performing farm or ranch labor during        
     twenty (20) or more calendar weeks?         YE              S      NO   

         If yes, enter the ending date of the twentieth week:            

  3.  During the preceding calendar year, did you: 

     a.  Employ seasonal workers in Texas on a truck farm, orchard or vineyard?              YES                 NO  
   
     b.  Employ migrant workers in Texas?        YES                    NO   

      c.  Employ seasonal workers in Texas working with migrant workers, at the same place and time during the same  
         week?           YES            NO       
   
 C-71 (052013)                                            (Page 1 of 2) 
  

 SECTION 4: REGULAR EMPLOYMENT 
  
 1.  Does your organization have a 501(c)(3) non-profit exemption from the Internal Revenue Service?                                         
      YES          NO     
      If yes, did you have at least four or more individuals in employment for a portion of at least one day during twenty 
      (20) or more different calendar weeks during the preceding year? 
      YES      NO        
    
      If yes, enter the ending date of the twentieth week:            
  
 2.  Enter the amount of wages paid during each calendar quarter of the year preceding January 1 of the termination  
      year: (Do not include Farm & Ranch or Domestic Employment) 
  
       Jan-Mar $             Apr-June $                        July-Sept $                                    Oct-Dec $             
  
 3.  During the preceding year did you have at least one individual in employment for a portion of at least one day 
      during twenty (20) or more different calendar weeks? 
      YES            NO  
  
      If yes, enter the ending date of the twentieth week:           
  
As of January 1,              (enter year), the undersigned employer hereby makes application for termination 
of coverage in accordance with the provisions of Section 206.004 of the Texas Unemployment 
Compensation Act, Labor Code. 

If the undersigned employer’s liability under the Texas Unemployment Compensation Act, Labor Code is 
terminated by approval of this application, this employer will lose all of their compensation experience; 
and if this employing unit again qualifies as a subject employer, the tax rate will be determined without 
regard to their compensation experience for periods prior to the effective date of termination coverage 
based on this application. 
 
The filing of this application or its approval does not relieve the applicant employer of his responsibility 
for filing all reports required by the Commission nor does it relieve the employer of liability for payment of 
all taxes, penalty and interest due for periods prior to the first day of the year with respect to which 
termination coverage is sought. 
                                                      
                                                                                                      Business Name of Applicant Employer 
 This application must be signed by the owner, a      
 partner, or corporate officer, or by a person whose 
 signature is authorized in accordance with Texas    Signed by 
 Workforce Commission Rules.                                                                               Owner, Partner or Officer 
  
                                                     Title                                                                             Date 
                                                      
 FOR TWC USE ONLY 
    (  ) APPROVED;           (                    ) DENIED 
  
 BY:                                                                                                                                          
       Texas Workforce Commission 
  
 DATE:                                                                                                                                        
  
            Individuals may receive, review and correct information that TWC collects about the individual by emailing to 
                                                                                                            th
           open.records@twc.state.tx.us or writing to TWC Open Records, 101 E. 15  St., Rm. 266, Austin, TX  78778-0001. 
                                                                     
C-71 (052013)                                          (Page 2 of 2)