Form Ncui 604 - Employer Status Report - 2012 Page 2
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218.
DOMESTIC EMPLOYERS:
Have you or will you pay $1,000 or more in a calendar quarter for domestic
______ /______/ _______
service in a private home, college club, fraternity or sorority? If yes, enter the
Yes
No
MM
DD
YYYY
date this occurred or will occur.
19.
NON-PROFIT ORGANIZATIONS: (Attach a copy of Federal Letter of Exemption under Section 501(c)(3) of the Internal
Revenue Code.)
Have you or will you employ four or more workers in 20 different calendar weeks
during a calendar year? If yes, enter the date this occurred or will occur.
Yes
No
______ /______/ _______
MM
DD
YYYY
20.
GOVERNMENTAL ENTITY:
(check one type below)
Federal
State
Local
Other: ________________________________________
21.
If you are not otherwise subject to the unemployment tax law under one of the preceding criteria (Items 15-
20), do you wish to voluntarily cover your employees for unemployment insurance?
Yes
No
22.
Have you ever paid Federal Unemployment Tax (FUTA)?
Yes
No
If yes, for what year(s)?
________
________
________
________
________
23.
If you have acquired, transferred assets or merged with another business, or made any other changes in the ownership of the
business, including changes, such as from a sole proprietorship to a corporation or a partnership, complete the following:
a.
Name of Former Owner: _____________________________________________________________________________
(Full Organizational Name, including Trade Name)
Former Owner’s N.C. UI Tax Number: _______________________________________
b.
Former Owner’s Address: ________________________________________
__________________
__ __
__________
c.
City
State
Zip Code
Street or P.O. Box
d.
On what date did you acquire or change the business?
______ /______/ _______
MM
DD
YYYY
Did you acquire all or a portion of the former owner’s North Carolina business?
e.
All
Portion (Specify) %______
f.
Was the business in operation at the time you acquired it?
Yes
No
Date Closed
______ /______/ _______
MM
DD
YYYY
g.
Was the business in bankruptcy at the time you acquired it?
Yes
No
h.
Does the former owner continue to have employees in North Carolina?
Yes
No
24.
Do you have workers who perform services for your business whom you consider to be self-employed or
independent contractors? If yes, see instructions for list to be attached.
Yes
No
25.
List owners (parent corporation, sole proprietor, ALL general partners, principal corporate officers, or members.) Attach a list of
those for which there is no space below.
______________________
______________________
_______________________
____________
_____________________
First Name
Middle Name
Last Name
Title
SSN or FEIN
_________________________________________
_______________________
__ __
___________
(____) ____ ______
Street or P.O. Box
City
State
Zip Code
Phone
______________________
______________________
_______________________
____________
_____________________
First Name
Middle Name
Last Name
Title
SSN or FEIN
_________________________________________
_______________________
__ __
__________
(____) ____ ______
Street or P.O. Box
City
State
Zip Code
Phone
______________________
______________________
_______________________
____________
_____________________
First Name
Middle Name
Last Name
Title
SSN or FEIN
_________________________________________
_______________________
__ __
__________
(____) ____ ______
Street or P.O. Box
City
State
Zip Code
Phone
Be Sure That All Applicable Items Are Completed Before Signing
I certify that the information entered on this form is true and accurate, and that I am authorized by the named employing unit to
complete this report for determining unemployment tax liability.
_____________________________________________
___________________________________
______ /______/ ________
Signature
Title
MM
DD
YYYY
NCUI 604 (Rev 02/2012)
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