Form 1 - Status Report
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1DWS-UI
Utah Department of Workforce Services
Form 1
Unemployment Insurance
Rev. 8/98
140 East 300 South - P.O. Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400
FAX (801) 526-9377
STATUS REPORT
READ INSTRUCTIONS ON REVERSE SIDE THEN COMPLETE ALL ITEMS
(TYPE OR PRINT LEGIBLY)
1. Type of Ownership
Individual
Partnership
Corporation
LLC
Other
2. Corporation, trade or business name and mailing address for quarterly contribution(tax)reports:
4. Federal Emp. I.D. Number
5. County in Utah where
6. Number of permanent
principal activity
worksites in Utah:
is located.
3. Telephone Number: (
)
Fax Number (
)
7. Mailing address for Wage and Separation
8. Street address of principal permanent work
9. Street address of business headquarters
Requests (if different from item 2):
site in Utah (if different from item 2, 7, or 9):
(if different from item 2):
10. List sole proprietor, general partners or corporate officers:
Name
Social Sec. #
Title
Home Address
Home Phone
11. Describe in detail your principal business product and/or service
12. If you are a new business in Utah,
show date business started.
READ INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING ANY ITEMS IN #14
14. Did you acquire the organization, trade, or business of another operator?
Yes
No
13. Date of first payment of wages in Utah:
Type of acquisition:
Change in form of ownership
Merger or reorganization
Sale, lease or sub-lease
Purchased assets through court
Other, please explain:
_____________________________________________________________________________
14a. Name, address and account number (if available) of previous operator (predecessor).
______________________________________ # ___________________________________ Date acquired _________________________
14b. Did you acquire all or a portion of the predecessor's organization, trade or business?
All
Part
90% or more
Less than 90%
14c. Did you retain all of the predecessor's employees?
Yes
No
14d. Is your predecessor still in business?
Yes
No
14e. Was predecessor's business closed prior to acquisition?
Yes
No
Date closed __________________
15. Enter below the amount of wages you have paid in Utah. If you have not paid wages enter "NONE."
Jan. 1 to March 31
April 1 to June 30
July 1 to Sept. 30
Oct. 1 to Dec. 31
Current
Year
Preceding
Year
16. If you have not paid wages, do you expect to in the future?
Yes
No
Show estimated date __________________________________
I certify that the information contained in this report is true and correct.
_____________________________________________________
_______________________ ______________________
______________
Name
Title
Telephone Number
Date
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