Form K-Cns 010 - Employer Status Report - Kansas Department Of Labor
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3KANSAS DEPARTMENT OF LABOR
Page 1 of 4
For Internal Use Only
Employer Status Report
SUBMIT ONLINE:
RETURN TO: Unemployment Contributions
Unemployment Insurance Liability Determination
P.O. Box 400
K-CNS 010 (Rev. 09-10)
Topeka, KS 66601-0400
FAX TO:
(785) 291-3425
(SEE INSTRUCTIONS ON PAGE 4)
PRINT CLEARLY in UPPER CASE - use BLACK INK
1. What is your type of organization / ownership? (check one below)
Individual
Limited Partnership
Estate
General Partnership
Joint Venture
Receivership
Limited Liability Company (LLC)
Corporation (Inc)
Trust
Limited Liability Partnership (LLP)
Governmental / Political Sub-Division (if checked, answer questions 2a and 2b)
Other Please describe:
2. If you are a government or political sub-division, select the branch of government and your finance option:
2a. Branch of government (check one)
2b. Finance option (check one)
State
Local
Indian Tribe
Contributing
Reimbursing
Rated Governmental
3. Are you a 501(c)(3) exempt organization?
Yes (if Yes, answer 3a and 3b)
No
3a. Finance Option
(check one)
Contributing
Reimbursing
3b. Have you received the 501(c)(3) exemption letter from the IRS?
Yes
No (if No, explain below)
4. Are you a Professional Employment Organization (P.E.O.)?
Yes
No
(If Yes, you must submit a separate K-CNS 015 for each client.)
5. Describe the major service, activity or product in Kansas that generates the most revenue for your business:
5b. Is your business considered to be in the construction industry?
Yes
No
6. Date you first paid wages in Kansas:
M
M
D
D
Y
Y
Y
Y
7. List your Federal Employer Identification Number (FEIN):
8. Legal business name:
(Inc, LLC, LP, Sole Prop, etc.)
9. Business or trade name:
(if different than # 8)
10. Business phone number:
Business fax
number:
11. Mailing address:
Street Number/PO Box
Direction
Street Name
Apt/Suite No
City
State
Zip + 4
12. Kansas business physical address:
Storefront/Physical Location
Job/Construction Site
Employee Residence
Apt/Suite No
Street Number
Direction
Street Name
City
State
Zip + 4
UNEMPLOYMENT INSURANCE CONTRIBUTIONS
P.O. Box 400, Topeka, KS • phone (785) 296-5027 • fax (785) 291-3425
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