Form Lwc-Es1 - Employer Application For La Unemployment Account

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LOUISIANA WORKFORCE COMMISSION

PHONE (225) 342-2944

EMPLOYER APPLICATION

U.I. Tax Liability and Adjudication

FAX

(225) 342-1943

for

P.O. Box 94186

FOR OFFICAL USE ONLY

LA UNEMPLOYMENT ACCOUNT

Baton Rouge, LA 70804-9186

ACCOUNT NO.

PLEASE REVIEW THE INSTRUCTIONS ON THE NEXT PAGE BEFORE COMPLETING THIS FORM

1. EMPLOYER or CORPORATION NAME

2. LA WITHHOLDING NUMBER

(Legal name is mandatory)

3. TRADE NAME or DBA NAME

4. FEDERAL EMP. I.D. NUMBER

5. MAILING ADDRESS (P.O. BOX OR STREET)

CITY

STATE

ZIP CODE

6. FAX NUMBER

7. PHYSICAL LOCATION IN LOUISIANA

(STREET)

CITY

STATE

ZIP CODE

8. TEL. NO. & EXT. (PHYSICAL LOCATION)

– mandatory

9. NAME OF CONTACT PERSON WITH PAYROLL RECORDS

10. TEL. NO. & EXT. (PAYROLL)

11. NAME AND ACCOUNT NUMBER OF PREVIOUS OR EXISTING LOUISIANA ACCOUNTS (Attach separate sheet if necessary)

12. E-MAIL ADDRESS

13. Type of Organization:

_______

Individual

Partnership

LLC

LLP

Corporation:

State

Date ___________________

Other

Government: Local

State

Funding type: General Appropriations

Self Generated

Mixed Funds

14A. Do you have a contract with a Professional Employer Organization (PEO)?

YES

If “YES,” complete the information on the line below.

____________________________________________________________

_____________

____________

PEO Name:

Fed ID:

Contract Date:

14B. Are you a Professional Employer Organization?

YES

If “YES,” provide a list of all clients with Fed. ID and UI numbers for each.

Use a separate sheet if necessary.

Note: If a bonded PEO, you will receive a mandatory quarterly Multiple Worksite Report to provide employment and wage breakouts for each client.

15. LIST BELOW THE OWNER OF SOLE PROPRIETORSHIP, ALL PARTNERS IN PARTNERSHIP, OR ALL OFFICERS OF CORPORATION. (Attach a separate sheet if necessary.)

NAME AND TITLE

SOC. SEC. NO.

RESIDENCE

TELEPHONE & EXT.

16. (A) REGULAR EMPLOYERS:

_____

Did you or will you have total wages in a calendar quarter equal to or greater than $1,500?

YES

If “YES,” Quarter

and Year

Did you or will you employ 1 or more employees in 20 weeks or more in a calendar year?

If “YES,” date of the 20th week.

YES

_____

Month

Day

Year

(B) AGRICULTURAL EMPLOYERS:

If “YES,” date of the 20th week.

_____

Did you or will you employ 10 or more employees in 20 weeks or more in a calendar year?

Month

Day

Year

YES

_____

Did you or will you have total wages in a calendar quarter equal to or greater than $20,000?

YES

If “YES,” Quarter

and Year

_____

Domestic employers must elect to file

Annually

Quarterly _______

_____

Did you or will you have total wages in a calendar quarter equal to or greater than $1,000?

YES

If “YES,” Quarter

and Year

_______

(D) NON-PROFIT EMPLOYERS:

Do you have a 501(c)(3) exemption from the Internal Revenue Service?

YES

If “YES,” you must attach a copy of your IRS 501(c)(3) exemption letter and answer 17. If “NO,” answer 16A.

_____

Did you employ 4 or more employees in 20 weeks or more in a calendar year?

YES

If “YES,” enter Month

Day _______ Year _______

Taxable

Reimbursable

17. LOCAL GOVERNMENT OR NON-PROFIT EMPLOYER:

Indicate the method you elect to pay taxes:

18. DATE ENTITY FIRST HAD EMPLOYEE(S) IN LOUISIANA: Month

Day

Year

# of employees:

18A.

19. ARE YOU APPLYING FOR A LETTER OF GOOD STANDING FOR LOTTERY PURPOSES ?

YES

___

____

20. ARE YOU LIABLE UNDER THE FEDERAL UNEMPLOYMENT TAX ACT (FUTA)?

YES

If “YES,” enter Month

Day

Year

State

21A. DID YOU ACQUIRE ANY OF THE ORGANIZATION, TRADE, BUSINESS,

B. IF YES, DID YOU ACQUIRE

C. IS THE BUSINESS ACQUIRED

OR ANY ASSETS OF ANOTHER LOUISIANA EMPLOYER OR HAD A

PART

ALL

STILL OPERATING IN LOUISIANA?

CHANGE IN YOUR FEDERAL ID#?

YES

OF THE LOUISIANA OPERATION?

If a partial acquisition, you must complete an Application for Partial Transfer. If not, the Agency may perform an audit to determine the data transfer.

D. NAME OF ORGANIZATION ACQUIRED

E. THEIR LA UNEMP. INS. NO.

F. DATE ACQUIRED OR FED. ID# CHANGED

22. ADDITIONAL LOUISIANA ORGANIZATION ACQUIRED

PART

ALL

C. THEIR LA UNEMP. INS. NO.

D. DATE ACQUIRED

B. STILL OPERATING:

YES

23. IF YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHO YOU CONSIDER TO BE INDEPENDENT CONTRACTORS, PLEASE READ #23 IN THE INSTRUCTIONS.

24. DESCRIBE YOUR BUSINESS ACTIVITY. THIS INFORMATION WILL DETERMINE YOUR U.I. TAX RATE. BE SPECIFIC!

List your main products or services in the space provided (i.e., full service restaurant, residential heating and air contractor, internet publisher). Manufacturers, provide the type of product and

materials used. If involved in more than one activity, provide approximate percentage of revenues or sales for each activity. Attach a separate sheet if additional space is needed.

Please provide us the name (print) and telephone number of the person who can supply additional information about your business activity.

_______________________________________________________________

__________________________________

Name

Telephone & Ext.

If employees work from home (i.e., sales representatives) in Louisiana, please give the Street, City, and Zip Code.

Street _______________________________________________________________ City _________________________________________________ Zip Code ______________

Signature and Title

Phone No.

Date

LWC-ES1web (REV. 12/2008)

ACCOUNT