Form De 1gs - Registration Form For Governmental Organizations, Public Schools, & Indian Tribes - 2011

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This form will be the basic record of YOUR Account.

EMPLOYMENT DEVELOPMENT DEPARTMENT

DO NOT FILE FORM UNTIL YOU HAVE PAID WAGES THAT EXCEED

Taxpayer Assistance Center, Attn: Specialized Coverage Desk

PO BOX 2068

$100.00 IN CALENDAR QUARTER.

RANCHO CORDOVA, 95741-2068

Please read INSTRUCTIONS on the back before completing form.

(916) 654-6288

Fax (916) 464-2904

PLEASE PRIN OR TYPE in BLUE OR BLACK INK ONLY.

Return form to

REGISTRATION FORM FOR GOVERNMENTAL ORGANIZATIONS, PUBLIC SCHOOLS, & INDIAN TRIBES

See reverse for registration instructions for other business types.

EDD ACCOUNT NUMBER

QUARTER

ONLINE PROCESS DATE

Dept. Use

Only:

A. LIST ALL PRINCIPAL OFFICERS OR

CALIFORNIA

TITLE

SOCIAL SECURITY #

ADMINISTRATORS

DRIVER’S LIC #

C. DATE OWNERSHIP

B. BUSINESS NAME:

D. FEDERAL TAX ID #:

(If none, enter N/A)

BEGAN OPERATING:

YYYY

E. ORGANIZATION OR TRIBE NAME:

F. PHYSICAL BUSINESS LOCATION:

CITY

STATE

ZIP CODE

PHONE NUMBER

(Number and Street, not P.O. Box)

(

)

G. MAILING ADDRESS:

CITY

STATE

ZIP CODE

PHONE NUMBER

(P.O. Box / Number and Street, only if different than F)

(

)

Note: If you have multiple CA locations, please attach the physical business addresses on a separate sheet of paper

H. INDICATE FIRST QUARTER & YEAR WAGES EXCEEDED $100:

Jan-Mar 20

Apr-Jun 20

Jul-Sept 20

Oct-Dec 20

First Payroll Date: MM

YYYY

I. HAVE YOU EVER OWNED OR BEEN A PRINCIPAL OWNER

J. FORMER EDD ACCOUNT NUMBER(S):

IN A BUSINESS REGISTERED WITH EDD?

BUSINESS NAME:

ADDRESS:

Yes

If Yes, complete J.

NOTE: If necessary, please provide additional information on a separate sheet.

K. WOULD YOU LIKE INFORMATION ON THE FOLLOWING ALTERNATIVE UNEMPLOYMENT INSURANCE FINANCING?

Reimbursable Cost of Benefits

School Employees Fund

Election of Disability Coverage

No, assign tax-rate method

L. TAXPAYER TYPE:

M. COUNTY WHERE BUSINESS IS LOCATED:

(SD) SCHOOL DISTRICT

(OT) OTHER (Specify)

(GO) GOVERNMENTAL

O. NUMBER OF

N. EMPLOYER TYPE:

EMPLOYEES:

(07) Public/Charter School

(11) Indian Tribe

(15) State Colleges

(21) Public Entity

(28) State Hospital

(08) District Hospital

(14) University of CA

(16) District Fair

(26) Fed-State Withholding

P. INDUSTRY ACTIVITY: Check the industry, product, or service that represents the greatest portion of your sales or revenue:

Services

Retail

Wholesale

Professional Employee Organization

Temp Services

Leasing Employer

Manufacturing

Other (Specify)

Also, describe specific product and/or service in detail:

Q. CONTACT PERSON FOR BUSINESS:

TITLE/COMPANY NAME:

ADDRESS:

PHONE: (

)

FAX: (

)

ADDRESS:

E-MAIL ADDRESS:

R. DECLARATION

I certify under penalty of perjury that the above information is true, correct, and complete, and that these actions are not being taken to receive a more

favorable Unemployment Insurance Rate. I further certify that I have the authority to sign on behalf of the above business.

Signature:

Title:

(Officer, Administrator, etc.)

Printed Name:

Telephone Number: (

)

Date:

S. PAYROLL TAX EDUCATION

Attend a payroll tax seminar that will help you understand how, what, and when to report State payroll taxes. Visit our Web site at

/Payroll_Tax_Seminars/

or call us at (888) 745-3886 for more information.