Form De 1gs - Registration Form For Governmental Organizations, Public Schools, And Indian Tribes

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This form will be the basic record of YOUR
EMPLOYMENT DEVELOPMENT DEPARTMENT
ACCOUNT. DO NOT FILE THIS FORM UNTIL
Taxpayer Assistance Center, Attn: Specialized Coverage Desk
YOU HAVE PAID WAGES THAT EXCEED
P.O. Box 2068
$100.00. Please read the INSTRUCTIONS on the
Rancho Cordova, CA 95741-2068
back before completing this form. PLEASE PRINT
(916) 654-6288 / FAX (916) 464-2904
OR TYPE. Return this form to:
REGISTRATION FORM FOR GOVERNMENTAL ORGANIZATIONS, PUBLIC SCHOOLS, & INDIAN TRIBES
ACCOUNT NUMBER
QUARTER
ON-LINE PROCESS DATE
TAS CODE
DEPT.
USE
Industry specific registration forms are required relative to each type of employer. Please use the appropriate form to register.
Commercial/Pacific Maritime/Fishing Boat
DE1
Household Workers
DE 1HW
Agricultural
DE 1AG
Non-Profit
DE 1NP
Government/Public Schools/Indian Tribes
DE 1GS
Personal Income Tax Only
DE 1P
A.
IF YES, ENTER THE FOLLOWING:
HAVE YOU EVER BEEN REGISTERED
ACCOUNT NUMBER
BUSINESS NAME
ADDRESS
PHONE NO.
WITH THE DEPARTMENT?
No
Yes
B.
INDICATE FIRST QUARTER AND YEAR IN WHICH WAGES EXCEEDED $100.
Jan.-Mar. 20
Apr.-June 20
July-Sept. 20
Oct.-Dec. 20
C.
ORGANIZATION TYPE
D.
COUNTY WHERE BUSINESS IS LOCATED
(SD) SCHOOL DISTRICT
(IT) INDIAN TRIBE
(GO) GOVERNMENTAL
(OT) OTHER (Specify)
E.
OWNERSHIP BEGAN OPERATING
FEDERAL I.D. NUMBER
BUSINESS NAME
MONTH:
DAY:
YEAR:
F.
NATURE OF ACTIVITY
ORGANIZATION OR TRIBE NAME
G.
TITLE
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE
List all principal officers or administrators
NUMBER
H.
CITY
STATE
ZIP CODE
PHONE NUMBER
MAILING ADDRESS
(
)
I.
CITY
STATE
ZIP CODE
PHONE NUMBER
BUSINESS ADDRESS (if different from mailing address)
(
)
J.
WOULD YOU LIKE INFORMATION ON THE FOLLOWING ALTERNATIVE UNEMPLOYMENT INSURANCE FINANCING?
Reimbursable Cost of Benefits
School Employees Fund
Election of Disability Coverage
No, assign tax-rate method
K.
NUMBER OF
EMPLOYER TYPE
EMPLOYEES
(07) Public/Charter School
(11) Indian Tribe
(15) State Colleges
(21) Public Entity
(28) State Hospital
(08) District Hospital
(14) University of CA
(16) District Fair
(26) Fed-State Withholdings
L.
SUPPORTIVE SERVICES
If you are part of a larger organization and you are primarily engaged in providing supportive services to other establishments of the larger
organization, check one of these boxes.
(1)
Control administrative (headquarters, etc.)
(3)
Storage (warehouse)
(5)
Does not apply
(2)
Research, development, or testing
(4)
Other (specify)
M.
CONTACT PERSON FOR BUSINESS
TITLE
ADDRESS
PHONE (
)
FAX
(
)
N.
DECLARATION
These statements are hereby declared to be correct to the best knowledge and belief of the undersigned.
Signature
Date
Residence Phone
(
)
Title
Residence Address
(Officer, Administrator, etc.)
Street
City
State
ZIP Code
O.
PAYROLL TAX EDUCATION: Attend a payroll tax seminar that will help you understand how, what, and when to report state payroll taxes.
Visit our Web site at /taxsem or call us at (888) 745-3886 for more information.
DE 1GS Rev. 6 (12-05) (INTERNET)
Page 1 of 2
CU

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