Form C-1 - Status Report Page 2
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2DOMESTIC - HOUSEHOLD EMPLOYMENT SECTION
COMPLETE 22 ONLY IF YOU HAVE DOMESTIC OR HOUSEHOLD EMPLOYEES
(INCLUDES MAIDS, COOKS, CHAUFFEURS, GARDENERS, ETC.)
22.
MONTH
DAY
YEAR
ENTER THE ENDING DATE OF THE FIRST CALENDAR QUARTER IN WHICH YOU PAID GROSS WAGES OF $1,000
OR MORE TO EMPLOYEES PERFORMING DOMESTIC SERVICE
:
NATURE OF ACTIVITY SECTION
23.
DESCRIBE FULLY THE NATURE
OF ACTIVITY IN TEXAS, AND
LIST THE PRINCIPAL PRODUCTS
OR SERVICES IN ORDER OF
IMPORTANCE:
24
PREVIOUS OWNER’S TWC ACCOUNT NUMBER (IF KNOWN)
DATE OF ACQUISITION
IF THE BUSINESS IN TEXAS WAS
ACQUIRED FROM ANOTHER
LEGAL ENTITY, YOU MUST
NAME OF PREVIOUS OWNER(S)
COMPLETE ITEMS 24-27.
ADDRESS
CITY
STATE
ZIP
WHAT PORTION OF BUSINESS WAS ACQUIRED? (CHECK ONE)
ALL
PART (SPECIFY)
25.
ON THE DATE OF THE ACQUISITION, WAS THE PREVIOUS OWNER(S), OR ANY PARTNER(S), OFFICER(S),
SHAREHOLDER(S), OTHER OWNER(S) OR A PERSON RELATED BY BLOOD OR MARRIAGE TO ANY OF THESE
INDIVIDUALS, HOLDING A LEGAL OR EQUITABLE INTEREST IN THE PREDECESSOR BUSINESS, ALSO AN
YES
NO
OWNER, PARTNER, OFFICER, SHAREHOLDER, OR OTHER OWNER OF A LEGAL OR EQUITABLE INTEREST IN
THE SUCCESSOR BUSINESS?
IF “YES”, CHECK ALL THAT APPLY:
SAME OWNER, OFFICER, PARTNER, OR SHAREHOLDER
SOLE PROPRIETOR INCORPORATING
SAME PARENT COMPANY
OTHER (DESCRIBE BELOW)
26.
IF “NO,” ON THE DATE OF THE ACQUISITION, DID THE PREVIOUS OWNER(S), PARTNER(S), OFFICER(S),
SHAREHOLDER(S), OTHER OWNER(S) OR A PERSON RELATED BY BLOOD OR MARRIAGE TO ANY OF THESE
INDIVIDUALS, HOLDING A LEGAL OR EQUITABLE INTEREST IN THE PREDECESSOR BUSINESS, HOLD AN
YES
NO
OPTION TO PURCHASE SUCH AN INTEREST IN THE SUCCESSOR BUSINESS?
27.
AFTER THE ACQUISITION, DID THE PREDECESSOR CONTINUE TO:
•
YES
NO
OWN OR MANAGE THE ORGANIZATION THAT CONDUCTS THE ORGANIZATION, TRADE OR BUSINESS?
•
YES
NO
OWN OR MANAGE THE ASSETS NECESSARY TO CONDUCT THE ORGANIZATION, TRADE OR BUSINESS?
•
CONTROL THROUGH SECURITY OR LEASE ARRANGEMENT THE ASSETS NECESSARY TO CONDUCT THE
YES
NO
ORGANIZATION, TRADE OR BUSINESS?
•
YES
NO
DIRECT THE INTERNAL AFFAIRS OR CONDUCT OF THE ORGANIZATION, TRADE OR BUSINESS?
IF “YES” TO ANY OF ABOVE, DESCRIBE:
VOLUNTARY ELECTION SECTION
28.
A NON-LIABLE EMPLOYER MAY ELECT TO PAY STATE UNEMPLOYMENT TAX VOLUNTARILY. IF AN EMPLOYER ELECTS TO DO SO, THE
EMPLOYER IS OBLIGED TO PAY TAXES FOR A MINIMUM OF TWO CALENDAR YEARS, BEGINNING WITH JANUARY 1 OF THE FIRST YEAR OF
THE ELECTION. THE EMPLOYER MAY WITHDRAW THE ELECTION BY WRITTEN REQUEST, AT THE END OF THE 2-YEAR PERIOD, IF NOT YET
LIABLE UNDER THE TEXAS UNEMPLOYMENT COMPENSATION ACT. TO ELECT THIS OPTION, COMPLETE THE FOLLOWING:
YES, EFFECTIVE JAN. 1, 2
I WISH TO COVER ALL EMPLOYEES (EXCEPT THOSE PERFORMING SERVICE(S) WHICH ARE
SPECIFICALLY EXEMPT IN THE TEXAS UNEMPLOYMENT COMPENSATION ACT).
SIGNATURE SECTION
I HEREBY CERTIFY THAT THE PRECEDING INFORMATION IS TRUE AND CORRECT, AND THAT I AM AUTHORIZED TO EXECUTE THIS STATUS
REPORT ON BEHALF OF THE EMPLOYING UNIT NAMED HEREIN. (THIS REPORT MUST BE SIGNED BY THE OWNER, OFFICER, PARTNER OR
INDIVIDUAL WITH A VALID WRITTEN AUTHORIZATION ON FILE WITH THE TEXAS WORKFORCE COMMISSION)
MONTH
DAY
YEAR
TITLE
DATE OF
SIGN HERE
SIGNATURE:
DRIVER'S LICENSE NUMBER
STATE
E-MAIL ADDRESS
Individuals may receive, review and correct information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to TWC
th
Open Records, 101 E. 15
St., Rm. 266, Austin, TX 78778-0001.
C-1BK (050907) Inv. No. 518050
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