Form De 1ag - Registration Form For Agricultural Employers

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This form will be the basic record of YOUR Account.
EMPLOYMENT DEVELOPMENT DEPARTMENT
ACCOUNT SERVICES GROUP, MIC 28
DO NOT FILE FORM UNTIL YOU HAVE PAID WAGES THAT
PO BOX 826880
EXCEED $100.00 IN CALENDAR QUARTER.
SACRAMENTO CA 94280-0001
Please read INSTRUCTIONS on the back before completing form.
888-745-3886
FAX 916-654-9211
PLEASE PRINT OR TYPE in BLUE OR BLACK INK ONLY.
Return form to:
REGISTRATION FORM FOR AGRICULTURAL EMPLOYERS
See reverse for registration instructions for other business types.
EDD ACCOUNT NUMBER
QUARTER
ONLINE PROCESS DATE
Dept. Use Only:
-
-
SOCIAL SECURITY
CALIFORNIA
A. LIST NAMES OF:
OWNER(S), PARTNER(S), CORP
TITLE
NUMBER
DRIVER’S LIC #
OFFICERS, OR LLC Members/Managers/Officers
Note: List additional partners, LLC members/officers/managers on a separate sheet
B. BUSINESS NAME:
C. DATE OWNERSHIP
D. FEDERAL TAX ID #:
(If none, enter N/A)
BEGAN OPERATING:
/DD
MM
/YYYY
E. CORPORATION / LLC NAME:
E1. SECRETARY OF STATE
(If none, enter N/A)
CORP / LLC ID #
F. DO YOU EMPLOY NONAGRICULTURAL WORKERS?
No
Yes
If yes, please enter: Account Number:
Business Name:
G. PHYSICAL BUSINESS LOCATION:
CITY
STATE ZIP CODE
PHONE NUMBER
(Number and Street, not P.O. Box)
(
)
H. MAILING ADDRESS:
CITY
STATE ZIP CODE
PHONE NUMBER
(P.O. Box/Number and Street, only if different than G)
(
)
Note: If you have multiple CA locations, please attach the physical business addresses on a separate sheet of paper
I. INDICATE FIRST QUARTER & YEAR WAGES EXCEEDED $100:
Jan-Mar 20
Apr-Jun 20
Jul-Sept 20
Oct-Dec 20
J. HAVE YOU EVER OWNED OR BEEN A PRINCIPAL OWNER
K. FORMER EDD ACCOUNT NUMBER(S):
IN A BUSINESS REGISTERED WITH EDD:
BUSINESS NAME:
No
Yes
If Yes, complete K.
ADDRESS:
NOTE: If necessary, please provide additional information on a separate sheet.
L. THIS IS A:
New Business
Hired Employees
Purchased a Business *
Other:
*
All
Part
If business was purchased, mark appropriate box and complete the information below:
1. Previous Owner
2. Previous Business Name
3. Previous EDD Account #
4. Purchase Price
5. Date of Transfer
Note: For all other changes in form/ownership to your account, please use the Change of Employer Account Information (DE 24)
N. LIST YOUR PRINCIPAL CROP(S), COMMODITIES, OR ACTIVITIES:
M. NUMBER OF CA EMPLOYEES:
See back for information on CA employees.
O. TAXPAYER TYPE:
Corporation
Other (Specify)
Individual Owner
Limited Liability Company
Co-Ownership
General Partnership
P. CONTACT PERSON FOR BUSINESS:
TITLE/COMPANY NAME
DAYTIME PHONE NUMBER
(
)
ADDRESS:
FAX NUMBER: (
)
E-MAIL ADDRESS:
BUSINESS WEBSITE:
Q. DECLARATION
I certify under penalty of perjury that the above information is true, correct and complete, and that these actions are not being taken to receive a
more favorable Unemployment Insurance Rate. I further certify that I have the authority to sign on behalf of the above business.
Signature:
Title:
(Owner, Corporate Officer, Partner, LLC Member/Manager, or authorized Agent)
Printed Name:
Phone Number: (
)
Date:
DE 1AG Rev. 10 (11-12) (INTERNET)
Page 1 of 2
CU

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