Form Ncui 604 - Employer Status Report - 2012
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1
2THIS REPORT IS REQUIRED OF EVERY EMPLOYING UNIT AND WILL BE USED TO DETERMINE LIABILITY UNDER
THE NORTH CAROLINA EMPLOYMENT SECURITY LAW, GENERAL STATUTE 96 AND DIVISION REGULATIONS.
Employer Status Report
Account No.
Liable
A/C/AS
For Agency Use Only:
Y N
Please Read Instructions!
Root
OW/OF
S Add
ET AL
S/PR
BR
Liab Date
NC Dept. of Commerce
Del After
Law Sec
M/W
County
ERA
Own
Division of Employment Security
Curr
P1
P2
P3
P4
P5
Next
Post Office Box 26504
Raleigh, N.C. 27611-6504
Orig
Ind Ctr
React Date
L Let
St Adj
TA
Please Type or Print in Black Ink
PC Let
or File Online
Return Within 10 Days
1.
Federal ID number:__________________
2. N.C. Dept. of Revenue withholding ID number:
3.
Enter any previously assigned North Carolina unemployment tax numbers:
4.
Employer name:
Enter exact name of legal entity – for further details see instructions)
5.
Trade name:
6.
Mailing address:
Street or P.O. Box
City
State
Zip Code
7.
Phone number: (_______)_____________________________
8. FAX number: (_______)
9.
Contact person: ________________________________________________
Title
Phone number: ( ______ )________________________ E-mail Address:
10.
N.C. business location:
Number of Employees expected
)
in the next 12 months:
Street (Do not use a post office box
N.C.
County
City
Zip Code
(Attach a list of ALL NC locations, if there is no NC business location, enter the primary employee’s home address)
11.
Check type of ownership:
Individual
Sub-Chapter S Corporation
LLC taxed as Individual
General Partnership
501(c)(3) -
LLC taxed as Partnership
Attach a copy
Corporation
Governmental
LLC taxed as Corporation
Limited Partnership -
Indian Tribal Governments/Enterprises
Attach a list of ALL General
Partners
Disregarded Entity
Other:
12.
Enter the principal activity or services performed in your North Carolina operation:
13.
If you are part of a larger organization and are primarily engaged in providing support services to that organization,
check one of the following:
Control, Administrative (Headquarters, etc.)
Storage/Warehouse
Research, Development or Testing
Other
14.
Enter date you first employed one or more workers in North Carolina: _________/________/___________
MM
DD
YYYY
For Items 15 through 20, check only the ONE item that applies
15.
GENERAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $1,500 or more?
Yes
No
_____/_______/_______
If yes, enter the date this occurred or will occur.
MM
DD
YYYY
b. Have you or will you employ at least one worker in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur.
Yes
No
_____/_______/_______
_____/_______/______
MM
DD
YYYY
16.
Are you an EMPLOYEE LEASING company?
Yes
No
17.
AGRICULTURAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $20,000 or more?
If yes, enter the date this occurred or will occur
Yes
No
_____/_______/_______
MM
DD
YYYY
b. Have you or will you employ at least 10 workers in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur.
Yes
No
_____/_______/_______
MM
DD
YYYY
OVER PLEASE
NCUI 604 (Rev 01/2012)
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