State Form 45982 - Status Report For Domestic (Household) Employment
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Original Report
STATUS REPORT FOR DOMESTIC (HOUSEHOLD) EMPLOYMENT
State Form 45982 (R6 / 2-13)
Amended
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N SENATE AVE., RM SE005, INDIANAPOLIS, IN 46204-2277
Toll Free: 1-800-437-9136 Fax: 317-233-2706
Preassigned
* This agency is requesting disclosure of your Social Security Number in accordance with
IC 22-4-19-6, IC 4-1-6;
discloure is mandatory and this record cannot be processed without it.
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
Payment Method
Merit Rate Start Date
(number and street)
Business Code
Merit Year Rate
City
State
%
%
Country Code
%
%
ZIP Code
Indiana County
%
County Code
%
__ __ __ __ __ - __ __ __ __ - __ __ - __
Reviewed By
__ __ - __ __ __ __ __ __ __
3. Federal ID Number:
Individual
Corporation
Partnership
Administrator
Estate
Trust
Guardian
Other Fiduciary (Type)
Domestic includes those services which are of a household nature in or about a private home or college fraternity.
4. On what date did you first employ individual(s) in the State of Indiana?
5. Did you pay $1,000 or more in wages to individuals employed in domestic services(s) during any calender quarter in either the current
/
or a preceding calendar year?
Yes
No
(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 domestic?
Yes
No
___ ___ ___ ___ ___ ___
(If yes, enter Indiana Unemployment account number.)
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
(month, day, year)
(
)
Preparer / Accountant Telephone Number
Employer Signature
Title
(See back of page for additional information.)
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Parent category: Business