Form Nucs-4058 - Supplemental Registration Form
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1SUPPLEMENTAL REGISTRATION FORM
AGRICULTURAL EMPLOYERS, DOMESTIC SERVICE
AND NONPROFIT ORGANIZATIONS
State of Nevada
Department of Employment, Training and Rehabilitation
Employment Security Division
500 E. Third Street
Carson City, Nevada 89713-0030
(775) 687-4545
Employer Name:
Mailing Address:
A. Are you subject to FUTA taxes in any state?
Yes
No
B. Number of employees (Please complete applicable section only)
Agricultural: Did you employ 10 or more persons in 20 weeks during the calendar year ?
Yes
No
Domestic:
Did you employ 1 or more persons during calendar year?
Yes
No
Nonprofit:
Did you employ 4 or more persons in 20 weeks during calendar year?
Yes
No
C. Date wages first paid in Nevada
RECORD OF NEVADA EMPLOYMENT IN PRECEDING CALENDAR YEAR
D.
List below the number of different individuals in your employ within each calendar week. (Include full and part-time employees. Also include salaried officers.)
January
February
March
April
May
June
Year
Week
Ending
Number
Employed
July
August
September
October
November
December
Year
Week
Ending
Number
Employed
(ESTIMATE IF NECESSARY)
E.
TOTAL WAGES: $________________
1st Qtr: $______________ 2nd Qtr: $______________ 3rd Qtr: $______________
4th Qtr: $ ___________
RECORD OF NEVADA EMPLOYMENT IN CURRENT CALENDAR YEAR
F.
List below the number of different individuals in your employ within each calendar week. (Include full and part-time employees. Also include salaried officers.)
January
February
March
April
May
June
Year
Week
Ending
Number
Employed
July
August
September
October
November
December
Year
Week
Ending
Number
Employed
(ESTIMATE IF NECESSARY)
G. TOTAL WAGES $_________________ 1st Qtr: $______________ 2nd Qtr: $_____________ 3rd Qtr: $______________
4th Qtr: $____________
.
:
DECLARATION
I certify that the information in this report is true and correct to the best of my knowledge and belief.
H
(If General Partnership or Joint Venture, more than one signature and title is required.)
____________________
_______________________________________________________________________________ _____________________________
Date
Signature (Owner, General Partners or Corporate Officer)
Title
____________________
______________________________________________________________________________
____________________________
Date
Signature (Owner, General Partners or Corporate Officer)
Title
Please read instructions on reverse of form .
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NUCS-4058 (Rev 2/00)
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