State Form 2837
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SUTA ACCOUNT NUMBER APPLICATION & DISCLOSURE STATEMENT
State Form 2837 (R9 / 3-15)
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N Senate Ave RM SE 202
Indianapolis, IN 46204‐2277
Confidential record pursuant To IC 4‐1‐16, IC 22‐4‐19‐6
* This agency is requesting disclosure of Social Security Numbers (SSNs) in accordance with IC 4‐1‐8‐1; disclosure is mandatory and this record cannot be processed without it.
IMPORTANT: Employer registration should be submitted on‐line at https://uplink.in.gov/ESS/ESSLogon.htm on or before the due
date of the employer’s first quarterly report. If the employer is unable to submit an on‐line application and disclosure statement, a
copy of this form, SF 2837, must be attached to the employer’s first quarterly contribution report (UC1S). Failure to timely register
an account or to complete the application and disclosure statement accurately may result in civil penalties as described in IC 22‐4‐
in.gov/dwd/SUTA.
htm
11.5‐9 being assessed to the Employer and / or to the non‐employer Agent. Please go to www.
for
additional information or clarification.
SECTION ONE – IDENTIFICATION OF THE REGISTRANT
What is the FEIN number to be used by this business to issue the
IRS W2 or 1099 to workers or contractors?
What is the FEIN or SSN* to be used by this business to report
business income to the IRS?
Leave blank if not required to report.
What is the complete, legal name of the business as registered with the Indiana Secretary of State?
Leave blank if not required to register. IDWD must be able to verify registration with the Indiana Secretary of State.
Date registered with the Indiana Secretary of State?
/
/
If not required to register with the Indiana Secretary of State, what is the legal name of the business used to secure the EIN from the IRS?
At what address will work be physically performed in Indiana? If registering for Tele‐work or similar activity, provide the worker’s address.
Do not use a PO Box. The state for this address defaults to Indiana. If no work is performed in Indiana, there is no Indiana SUTA liability.
Street
City
Complete SF48812, Indiana Business Location Report, for additional
ZIP
‐
locations.
What is the address at which legal notices are to be served (mailing address for the business)?
Do not use a third party agent address.
Street
City
State
ZIP
‐
US
Canada
Mexico
Other
What is the telephone number for the business? Do not use a third party agent phone number.
Ext or
‐
‐
Telephone
Name
‐
‐
Fax
Please provide an email address where IDWD may contact a responsible party for the business. Leave blank if not applicable.
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