Ui-1 R 12/06 - Status Registration - Mississippi Department Of Employment Security
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UI-1
STATUS REGISTRATION
Please type or print. Always complete entire form.
MDES OFFICIAL INFORMATION
Found Date
(MM/DD/CCYY):
DO NOT WRITE ABOVE THIS LINE.
EMPLOYER ENTITY INFORMATION
-
1. Federal Employer ID Number (FEIN):
2. Organization Type:
Corporation
Partnership
Individual
Non-Profit Corp.
Corporate LLC
Partnership LLC
Individual LLC
Other (enter type):
3. IF A CORPORATION: a. State of Incorporation:
b. Date of Incorporation
c. State of Legal Domicile:
(MM/DD/CCYY):
4. IF INDIVIDUAL OWNER:
Do you employ any individual(s) not including yourself, your spouse or your children under 21 years of age? YES
NO
5. Legal Entity Name:
6. Business Name (D/B/A):
7. a. If Yes, provide the date
you first
(MM/DD/CCYY)
7. Have you paid employees for work performed in Mississippi?
YES
NO
employed someone in Mississippi:
8. Does this business consist solely of agricultural work?
YES
NO
9. Does this business employ domestic help?
YES
NO
(This includes housekeepers, sitters, or other domestic employment)
10. Are you applying for reimbursable status under the Indian Tribal Law?
YES
NO
11. Is this organization a State College, State University or State Hospital?
YES
NO
12. Is this business FUTA (Federal Unemployment Tax) liable in another state?
YES
NO
13. Are you a Professional Baseball Concessionaire?
YES
NO
14. Do you have a Third Party that handles your payoll and/or tax matters?
YES
NO
a. If Yes, Third Party authorized to handle matters for Unemployment Tax:
b. Agent/Officer Phone:
Name:
-
(
)
ext.
Title:
15. Do you have business location(s) in Mississippi?
YES
NO
a. If Yes, list below your places of business in Mississippi and give a description of your operations at each place of business.
City
County
Number of Employees
Principal Business Activity
16. Are you exempt as an IRS 501 (C) (3) Non-Profit Organization?
YES
NO
a. If Yes, attach a copy of your 501(C) (3) exemption.
EMPLOYER CONTACT DETAILS
1. Physical Address
Address:
City:
State:
Country:
ZIP Code:
-
Phone:
(
)
2. Unemployment Tax Mailing Address
Same as previous
Attention:
Address:
City:
State:
Country:
ZIP Code:
-
Phone: (
)
-
Contact Name (First, MI, Last):
Phone: (
)
ext.
3. Unemployment Claims Mailing Address Same as previous
Address:
City:
State:
Country:
ZIP Code:
Phone: (
)
-
FAX: (
)
-
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address:
Auxiliary aids and services are available upon request to individuals with disabilities.
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