Form A - Application For Tax Registration And Unemployment Contributions
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1
2MAINE REVENUE SERVICES AND DEPARTMENT OF LABOR
FORM
APPLICATION FOR TAX REGISTRATION
A
AND UNEMPLOYMENT CONTRIBUTIONS
*981093000*
Return Application to: Department of Labor, Central Registration Section, P.O. Box 1057, Augusta, ME 04332-1057
SECTION 1 — TAXPAYER INFORMATION
1. BUSINESS INFORMATION
Are you applying for status as a:
Common Pay Master
Common Pay Agent
Legal Name ___________________________________________
Doing Business As _____________________________________________________
Social Security Number _________________________________
Business Phone Number _________________________________________________
Fed. Employer’s ID # (FEIN) ______________________________
Street Address of Business Location (Physical Location) ________________________
__________________________________________________
Primary Mailing Address _________________________________
______________________________________
__________________________________________________
2. TYPE OF OWNERSHIP (check appropriate box)
Sole Proprietor
Partnership
Estate
C Corporation (Regular)
Limited Partnership
Trust
S Corporation (Sub “S”)
Limited Liability Company
Association
Corporation (Non Profit)
Non Profit Organization (501(c)(3))
Other
(attach copy of exemption letter)
If you marked “Other”, please explain type of ownership _________________________________________________________________________________
Corporations — Date Incorporated _________________________________
State of Incorporation ___________________________________________
Limited Partnerships — Date Registered ____________________________
State of Registration ____________________________________________
Limited Liability Co.’s — Date Registered ____________________________
State of Registration ____________________________________________
3. BUSINESS DESCRIPTION/PRINCIPAL ACTIVITY: _________________________________________________________________________________
4. OWNER INFORMATION (Names of Partners or Officers, Name of Trustee or Personal Representative)
Name & Title __________________________________________
Name & Title __________________________________________________________
% of Business Owned ___________
% of Business Owned __________
Social Security Number _________________________________
Social Security Number __________________________________________________
Address ______________________________________________
Address ______________________________________________________________
____________________________________________________
_____________________________________________________________________
EMPLOYERS REGISTERING WITH THE DEPARTMENT OF LABOR, PLEASE SEE SPECIFIC INSTRUCTIONS ON PAGE 11 FOR QUESTIONS 5 and 6.
5. DO YOU OWN OTHER BUSINESSES?
Other Business Name ___________________________________
Other Business Name ___________________________________________________
Fed. Employer’s ID No. (FEIN) ____________________________
Fed. Employer’s ID No. (FEIN) _____________________________________________
UC Employer Account No. _______________________________
UC Employer Account No. ________________________________________________
Address ______________________________________________
Address ______________________________________________________________
______________________________________
__________________________________________________
6. BUSINESS ACQUISITION INFORMATION
Business Acquisition Date __________________________
How was Business Acquired?
Did you acquire all of the previous owners business or assets?
Yes
No
Purchase
Foreclosure Sale
If no, what part of the business did you acquire? _____________________________________________
Merger
Other (describe)
Previous Owner’s Name ____________________________________________________________________
Previous Owner’s Address __________________________________________________________________
REQUIRED INFORMATION:
Previous Owner’s: Sales Tax Registration No. ______________________________
UC Employer Account No. _______________________________
Did the previous owner do business in Maine? Yes
No
Did the previous owner have employment in Maine? Yes
No
7. FEDERAL UNEMPLOYMENT TAX
Is your organization subject to the Federal Unemployment Tax? (If unknown, leave blank.)
Yes
No
If yes, first date of employment in Maine _________________________
SECTION 2 — WITHHOLDING TAX — (If you complete this section, you must complete Section 3.)
8. REGISTRATION DATE FOR WITHHOLDING TAX: ___________________________
This is the date you began withholding Maine income tax or were required to withhold Maine income tax.
9. ESTIMATED ANNUAL WITHHOLDING TAX LIABILITY
Payment Frequency
Withholding of
Complete Section 3 to register as an employer with
Semi-Weekly
$18,000 or more per year
the Department of Labor and to file unemployment
insurance contributions and employer wage reports.
Quarterly
less than $18,000 per year
10. WITHHOLDING TAX ACCOUNT ADDRESS
ADDRESS _____________________________________________
ATTENTION: _________________________________________________________
_____________________________________________________
PHONE NUMBER _____________________________________________________
ALL APPLICANTS MUST COMPLETE SECTION 1. COMPLETE OTHER SECTIONS AS NEEDED.
FORM
*PLEASE SIGN APPLICATION ON REVERSE SIDE*
A
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Parent category: Legal