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Document Number: UCT-681
Description: This form can only be used by Wisconsin employers who are 501(c)(3) Nonprofit Organizations or Indian Tribes as an assurance of reimbursement.
Comments: Questions or comments regarding this form please contact the Reimbursement Specialist at (608) 266-9989.
Document Attachment: UCT-681 (pdf/40 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.