Form Lb-0443 - Report To Determine Status
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1
2REPORT TO DETERMINE STATUS
EMPLOYER SERVICES
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
STATE AND LOCAL GOVERNMENT
500 JAMES ROBERTSON PKWY, 8TH FLOOR
NASHVILLE TN 37245-3555
(615)741-2486
FAX (615)741-7214
Tennessee ID#
OFFICIAL USE ONLY
M. No.
SIC
County
Area
1. Enter Federal Number, Business Name and Address
Federal No. ___ ___ ___ ___ ___ ___ ___ ___ ___
Liab. Org.
Date Liable
First Employment
Rate
Name
_______________________________________
Ind GI
Comp Year
Status Rec Date
ROC
MS IC
_______________________________________
Previous No.
S I C 6
M SIC -6
AUX-SIC
Address _______________________________________
_______________________________________
VERIFIED
_______________________________________
Note: Attach copy of Ordinance creating your
governmental organization.
2. PHYSICAL ADDRESS in Tennessee if different from above: ____________________________________________________________
_______________________________________________________________ PHONE ___________________________________
Check (X)
3. (a) Type of organization:
State Government ___________
Local Government __________
(b) List below all State or Local governmental agencies or departments that will report under this account number.
Agency or Department
Address
County
Nature of Service
Number of Employees
Attach list if additional space is needed.
(c) List three (3) principal officers or officials:
(1) Name _________________________
(2) Name _________________________
(3) Name _________________________
(1) Title __________________________
(2) Title ___________________________
(3) Title ___________________________
4. Give date you first had employees in Tennessee ______________________________________________________________________
5. Do you wish to elect to reimburse the Department of Labor and Workforce Development for benefits paid in lieu of premiums.
YES o
NO o
If answer is “YES,” complete Reimbursement Election on page 2 of this form. *(See Page 2)
* Reimbursement employers are liable for all benefits based on wages paid by them including overpayments based on administrative
errors or improper employer reporting.
THIS REPORT MUST BE SIGNED BY AN AUTHORIZED OFFICIAL.
DATE
BY
TITLE
(Signature)
RETURN TO:
EMPLOYER SERVICES
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
500 JAMES ROBERTSON PKWY, 8TH FLOOR
NASHVILLE TN 37245-3555
LB-0443 (R12/03) INTERNET
RDA N/A
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