Apply for benefit charge offset

Before submitting:
Read about who is eligible and how to apply on our website.

To submit:
Complete the Benefit Charge Offset Application Template and upload below. If you’re not applying for a benefit charge offset, please don’t submit this form.

To prevent errors, format Social Security numbers using dashes.

By submitting the template, you are affirming that all employees on your list meet both criteria for the offset program as explained on our website.

Upload template

Important: Document file name must end with extension csv.

If you're not reporting a Benefit Charge offset, don't submit this form.