State Form 52098 - Determination Of Professional Employer Organization (Peo) Status - Indiana Department Of Workforce Development Page 2

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10.
Is any commonly owned, managed or controlled PEO reporting wages at the PEO or
client level in the State of Indiana? If 'yes', please provide the name, FEIN, and state unemployment tax
Yes
No
account number(s) of the affiliated PEO(s).
Name______________________________________
Name______________________________________
FEIN______________________________________
FEIN______________________________________
UTA number_____________________________________
SUTA number_____________________________________
List all names that the registrant has operated under in the last five years. Please include the name of any
11.
predecessors and successors.
Yes
12.
Are you registering as a result of a transfer of trade or
If 'yes', you must complete
business as described in IC 22-4-10-6 or IC 22-4-11.5.
"Section A" below.
No
SECTION A if you have any questions whether or not this section applies to you, please call 1-800-437-9136.
Date you purchased, reorganized, incorporated or otherwise took control of the Indiana business:______________
Predecessor/Disposer Federal Identification number:_____________________________________________________________
Predecesor/Disposer Legal name______________________________________________________________________
Trade name (or d/b/a): ______________________________________________________________________________
Mailing address:_____________________________________________________________________________________
City: _______________________ State:___________ ZIP code:_____________Telephone number:(_____)_____-________
Disposer contact person first name:___________________________Last name:_______________________________
Disposer contact person telephone number: (______)_______-_____________
REMARKS: Please attach additional sheets of paper if more space is needed.
I hereby certify that all information contained herein is true, correct and complete to the best of my knowledge and belief.
________________________________________
_________________________________
Signature
Date (mm/dd/yyyy)
Indiana Department of Workforce Development
Mail this form to:
10 N. Senate Ave., RM SE 202, Indianapolis, IN 46204-2277
Please call 1-800-437-9136, if you have any questions.

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