APPLICATION TO EXEMPT CORPORATE OFFICERS                                                            UI/TAX & FIELD SERVICES
                 OR LIMITED LIABILITY COMPANY MANAGERS                                                                                        P.O. BOX 5507
                 FROM UNEMPLOYMENT INSURANCE COVERAGE                                                                Bismarck ND 58506-5507
                 JOB SERVICE NORTH DAKOTA                                                                                                     701-328-2814
                 UNEMPLOYMENT INSURANCE                                                                                                       FAX 701-328-1882
                 SFN 18411 (R. 2-19)                                                                            TTY:  Relay ND 800-366-6888

Section 52-01-01(14) of the North Dakota Unemployment Compensation Law provides that officers of a corporation, and
managers of Limited Liability Companies (LLCs) treated as corporations for federal income tax purposes, and those managers of
any LLC who are not members, are considered employees. However, some of these employees may apply to exclude their wages
from employment.  Section 52-01-01(17)(a)(1) and (2) provide that: 

  "If a corporate officer is employed by a corporation in which one-fourth or more of the ownership interest, however designated, is owned or
controlled by the officer or by the officer's parent, child, or spouse, or by any combination of them, the corporation with the concurrence of the
officer may exclude that officer's service from employment as of the first day of January of any calendar year if, during January of that year, the
corporation files a written application to exclude the officer's service from employment or as of the formation of the corporation if, within sixty days
of the formation, the corporation files a written application to exclude the officer's service from employment."

  "If a limited liability company manager is employed by the limited liability company in which one-fourth or more of the ownership interest,
however designated, is owned or controlled by the manager or by the manager's parent, child, spouse, or by any combination of them, the limited
liability company with the concurrence of the manager may exclude that manager's service from employment as of the first day of January of any
calendar year if, during January of that year, the limited liability company files a written application to exclude the manager's service from
employment or as of the formation of the limited liability company if, within sixty days of the formation, the limited liability company files a written
application to exclude the manager's service from employment. This exclusion does not apply to any limited liability company that is wholly owned
by or operates as an Indian tribe, state or local government, or nonprofit organization with respect to services performed for those entities which
are required by federal law to be covered under the North Dakota unemployment compensation law."

Wages exempted under this provision will not be subject to North Dakota unemployment insurance taxes or usable on future
claims for unemployment insurance benefits. 
The employer should be aware that the Federal Unemployment Tax Act does not provide for this exemption.  FUTA tax 
ramifications should be examined before selecting this option. 

Business Name                                                    Corporate or Legal Name

                                                                 Unemployment Insurance Account No.
Officers/Managers to be excluded:
                                                   Social          %
  Name           Title                 Security Number*          Ownership**                             Signature***

I certify that the officers/managers listed above meet the exemption requirements.
Signature of Authorized Representative                            Phone                                  Date

This application must be delivered or mailed to the address above by January 31 of the year in which the exemption is to become 
effective or within 60 days of the formation of the corporation or Limited Liability Company (LLC).  If you have not received a 
confirmation of receipt within 15 days, please call 701-328-2814.
If you are mailing your application, it is highly recommended that you obtain an official receipt as proof of mailing in the event it is not 
received by JSND.
JSND will notify you in writing of the acceptance or denial of your application.

* In compliance with the Privacy Act of 1974, a social security number is mandatory on this form pursuant to 20 CFR 666.150 and/or North
  Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility
  purposes, and program performance accountability.
**   If ownership is less than 25%, indicate relationship that qualifies this individual for exemption.
*** Signature indicates the officer/manager consents to be excluded from unemployment insurance coverage.
                 Job Service North Dakota is an equal opportunity employer/program provider.
                 Auxiliary aids and services are available upon request to individuals with disabilities.