Form Ui-1 Application For Unemployment Insurance Employer Reserve Account Page 2
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2UI-1, Page 2
(V-3)
PART IV - DOMESTIC (HOUSEHOLD) EMPLOYMENT
17.
Date on which you first employed a worker in domestic employment in Kentucky (month, day, year):
18.
Have you or do you expect to have a quarterly domestic (household) payroll of at least $1,000.00?
YES
NO
If yes, in what month and year did (or Will) this first occur?
Month
Year
PART V - AGRICULTURAL EMPLOYMENT (INCLUDE CORPORATE OFFICERS!)
19.
Date on which you first employed a worker in agricultural employment in Kentucky (month, day, year):
20.
Have you or do you expect to have a quarterly agricultural payroll of at least $20,000.00; or, have you or do you
expect to employ at least 10 agricultural workers in 20 different weeks during a calendar year?
YES
NO
If yes, in what month and year did (or will) this first occur?
Month
Year
PART VI - ACQUISITION OF EXISTING BUSINESS - To be completed by both the transferring and acquiring parties.
21.
ENTER DATE OF TRANSFER AND STATUS OF OWNERSHIP PRIOR TO TRANSFER
DATE OF TRANSFER
EMPLOYER NO.
FEDERAL NO.
Names of Owner/s or Officer/s
Phone
(
)
TYPE OF OWNERSHIP
REASON FOR CHANGE
Proprietorship
Sold........................
Leased..................
Partnership
Corporation
Lease Reverted.......
Other (Explain).....
Other (Explain)
TYPE OF CHANGE
Trade or Business Name & Address
Transferred in Entirety (ALL KY OPERATIONS)...
(Complete #22 - Both Parties Must Sign)
Transferred in Part.....................................................
(Complete #22, 23, 24, 25 & 26 - Both Parties Must Sign
22.
ENTER DATA FOR NEW OWNERSHIP
EMPLOYER NO.
FEDERAL NO.
Name, Address & S.S. # of Owner/s or Officer/s
TYPE OF OWNERSHIP
TRADE OR BUSINESS NAME, ADDRESS & ZIP CODE
Proprietorship
Partnership
Corporation
Other (Explain)
Location of Business in Kentucky (Street, City, Zip Code)
Phone
(
)
Principal Activity
Principal Product
23.
ENTER DATA FOR RETAINED PORTION
EMPLOYER NO.
FEDERAL NO.
TRADE OR BUSINESS NAME, ADDRESS & ZIP CODE
Name, Address & S.S. # of Owner/s or Officer/s
TYPE OF OWNERSHIP
Proprietorship
Partnership
Corporation
Other (Explain)
Phone
(
)
Principal Activity
Principal Product
Location of Business in Kentucky (Street, City, Zip Code)
24.
Portion of prior owner/operator’s reserve account to be transferred:
%
25.
Percentage of reserve transferred must be based on payroll or number of employees transferred. Please indicate which basis has been used.
26.
Predecessor’s date of first employment for transferred portion.
Signature & Title of Transferor or
Signature & Title of Transferee or
Date
Disposing Employer Shown in Part 1
Acquiring Employer Shown in Part 2
(Owner or Officer)
(Owner or Officer)
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