Form K-Cns 010 - Employer Status Report - Kansas Department Of Labor Page 3
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3KANSAS DEPARTMENT OF LABOR
Page 3 of 4
K-CNS 010 (Rev. 09-10)
17. In which WEEK did you establish liability based on the number of weeks of employment?
(Please indicate the week in which you established liability. Note: Refer to instructions for more detail.)
Yes
No
18. Did you acquire / purchase All or Part of an existing business?
18a. Date acquired / purchased:
All
Part
% acquired
M
M
D
D
Y
Y
Y
Y
Yes
No
18b. Is the prior owner continuing business in Kansas?
If yes, explain below:
Yes
No
18c. Do you wish to accept the prior owner's Unemployment Tax Rate?
Prior owner's Kansas
18d. Name of prior owner:
Employer Serial Number:
18e. Prior business or
Current phone
trade name:
number:
18f. Prior owner's current address:
Street Number/PO Box
Direction
Street Name
Apt/Suite No
City
State
Zip + 4
K.S.A. 44-7710a(b)(2) allows a successor, defined in K.S.A. 44-703(h)(4) and K.S.A. 44-703(dd), the choice to acquire the experience rating factors of the
predecessor employer. The request for transfer must be made in writing within 120 days of the acquisition. The experience rating factors are all of the
unemployment taxes paid, annual payrolls and benefit charges of the predecessor employer. These factors are used to compute your unemployment tax rate for
subsequent years. Alternately, successor employers may elect to be assigned their industry tax rate.
No multiple locations
19. For the last three years, list any multiple business locations you have operated in KANSAS
Trade Name and Address
Date Opened
Date Closed
Number of Employees
Business Activity
20. Are you subject to the Federal Unemployment Tax Act (FUTA)?
Current Year
Yes
No
Prior Year
Yes
No
21. If no liability is indicated, do you wish to elect coverage?
Yes, beginning January 1 of the current year, or at the commencement of employment, and continuing for not less than two calendar
years, on behalf of the employing unit, I voluntarily elect to: (select one or both)
to become an employer described in K.S.A. 44-703(h), the same as other employers, even though no mandatory coverage is indicated
to extend coverage to all workers performing services that are excluded from coverage as described in K.S.A. 44-703(i)
No
Yes
No
22. Are you continuing to pay wages in KANSAS?
Yes
No
23. Do you have individuals performing services you believe are not employees?
If yes, explain below. Attach additional pages if necessary.
24. Would you like to have a KDOL representative contact you directly to provide additional information on exemptions, payment
options for governmental/political sub-divisions or 501(C)(3) entities, successorship or any other status report information?
Yes
No
25. I certify that the information I have provided on this report is complete, correct and true to the best of my knowledge and belief.
Date
Signed
M
M
D
D
Y
Y
Y
Y
Signature of owner, partner, member/manager, corporate officer, etc.
Title - owner, partner, m/m, corporate
officer, etc.
The information requested in this report is required to be provided by K.S.A. 44-714(f) and K.A.R. 50-2-5. It will be used only by
public officials in the performance of their public duties. Section 6103(d) of the Internal Revenue Code authorizes IRS to
UNEMPLOYMENT INSURANCE CONTRIBUTIONS
exchange information with us for audits and certifications.
P.O. Box 400, Topeka, KS • phone (785) 296-5027 • fax (785) 291-3425
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