Form Deed-13 - Report To Determine Liability For Unemployment Tax - 2003 Page 2
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3REPORT TO DETERMINE LIABILITY FOR UNEMPLOYMENT TAX (continued)
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Write in your Minnesota UI Employer Account Number:
12.
INDEPENDENT CONTRACTOR OR EMPLOYEES? This department renders opinions and issues formal
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determinations regarding classification of workers.
If you have or
contemplate hiring independ
ent
SEND
INFORMATION
contractors check the box to receive information on the factors considered in making these determinations.
13.
SUCCESSION: Complete this section if you have acquired, purchased, leased, or assumed all or any part of an existing
Minnesota business.
This includes a new legal entity formed through reorganization by substantially the same ownership.
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New legal entity formed by substantially the same ownership by reorganization (i.e. sole proprietorship to corporation)
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Acquisition, purchase, lease, or assumption of all or any part of an existing Minnesota business or its assets.
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Corporate stock changed hands without formation of a new corporation or assignment of new Federal ID Number
(FEIN)
14.
Date of reorganization or acquisition
_____________________________
15.
Trade name and full street address of business acquired:
16.
Minnesota UI Employer Account Number of previous business, if known:
___ ___ ___ ___ ___ ___ ___
- ___ ___ ___
17.
Name, address, and telephone number of previous owner:
Telephone:
(_______) ________-____________
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18.
Is the previous owner (predecessor) still doing business in Minnesota?
Yes
No
Unknown
19.
What percentage of your predecessor’s assets did you acquire?
20.
How many of your predecessor’s employment positions have you continued? _____ How many have you not continued? _____
21.
Is there 25% or more common ownership between the new business (successor) and the previous business (predecessor)?
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Refer to instructions #21
Yes
No
A.
If yes, list the owners that are common to both the predecessor and the successor and their relationship.
For each of these common owners, identify the percentage of ownership in b oth the predecessor and successor businesses.
Predecessor Owner
% of Pred
Successor Owner
% of Succ
Relationship
Ownership
Ownership
B.
If you answered yes to #21 and you acquired only a portion of your predecessor’s business, do you
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wish to apply for that portion of your predecessor’s employment experience by furnishing payroll
Yes
No
information?
22.
Ownership:
Please print or type.
This report must be signed by the owner, all partners, or authorized off
icers.
Attach additional sheets if necessary.
I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.
Full Legal Name
Title
Social Security #
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
Full Legal Name
Title
Social Security #
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
23. Name and title of form preparer
Phone #
Date
DEED-13
(rev. 09-2003)
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