State Form 46798 - Status Report Agricultural Employment
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1STATUS REPORT AGRICULTURAL EMPLOYMENT
Original Report
State Form 46798 (R3 / 7-05)
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
Amended
10 N SENATE AVE RM SE106 INDIANAPOLIS IN 46204-2277
Local: 317-232-7436 Toll Free: 1-800-891-6499 Fax: 317-233-2706
Preassigned
CONFIDENTIAL RECORD Pursuant to IC 22-4-19-6, IC 4-1-6
OFFICE USE ONLY
Please type or print in ink.
Account Number
Effective Date
1. Legal Name of Employing Unit
Under Section
Qualified On
2. Street Address
Pymt. Method
Merit Rate Start Date
Business Type
Merit Year Rate
City
State
%
%
Country Code
%
%
ZIP Code
Indiana County
%
County Code
%
__ __ __ __ __ - __ __ __ __ - __ __ - __
Reviewed By
__ __ - __ __ __ __ __ __ __
3. Federal ID Number:
Individual
Corporation
Partnership
Administrator
Other (specify)
Trust
Guardian
Other Fiduciary
4. On what date did you first employ individual(s) in the State of Indiana?
5. Did you pay $20,000 or more in wages to individuals employed in agricultural labor during any calender quarter in either the current or
/
a preceding calendar year?
Yes(Quarter/Year)
6. Name
Name
Title
Title
Social Security Number
Social Security Number
Residence Telephone Number
Residence Telephone Number
7. Are you an employer under Indiana Law for employees other than agricultural?
Yes
No
(if yes, enter Indiana Unemployment account number) ___ ___ ___ ___ ___ ___
8. Did you employ 10 or more individuals in agricultural labor for some portion of a day (not necessarily at the same time of the day) in
each of 20 different calendar weeks, whether or not such weeks were consecutive, during either the current or preceding calendar
year?
Yes
No
I hereby certify that I have carefully examined the foregoing questions and that my answers thereto and all information contained
herein are true and complete to the best of my knowledge and belief.
Prepared By
Title
Date
(
)
Preparer / Accountant Phone Number
Employer Signature
Date
(See back of page for additional information)
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Parent category: Business