Form Uitl-100 - Application For Unemployment Insurance Account May 2011 Page 3

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Department Use Only

15. Did the business entity acquire or hire any workers from the prior business who are now employed with the new business?

Yes

If Yes: How many employees were acquired?

How many employees did the prior business have during its last four pay periods?

Last Pay Period

Second-to-Last Pay Period

Third-to-Last Pay Period

Fourth-to-Last Pay Period

16. Provide the following information regarding the prior employer.

Prior Legal Business Name

Prior FEIN or UI Account Number

Name of Prior Owner

Current Telephone Number of Prior Owner

Complete Current Address of Prior Owner (include city, state, and ZIP code)

17. In accordance with the Colorado Employment Security Act (CESA), employers are required to provide UI coverage if one of the following conditions are

met. Employers can meet these conditions through the employment of full-time, part-time, and temporary workers (including temporary agricultural workers

with an H-2A visa).

NOTE: Calendar quarters are defined as January–March, April–June, July–September, and October–December.

Check the appropriate box and provide the corresponding information that is requested.

Commercial, Industrial, or Professional Organization (as defined in CESA 8-70-113)

Paid one or more workers a total of $1,500 in gross wages during any calendar quarter in the current or preceding calendar year

Date on which you paid $1,500 in gross wages during a calendar quarter to meet this requirement

Employed one or more workers for some portion of a day in 20 different calendar weeks during the current or preceding calendar year (all 20 calendar

weeks must occur within the same calendar year)

NOTE: The services do not have to be performed in consecutive weeks or by the same employee.

Date on which you first employed a worker for some portion of a day to meet this requirement

Date on which you employed a worker for some portion of a day in the 20

calendar week to meet this requirement

Agricultural Employer (as defined in CESA 8-70-120)

Paid one or more agricultural workers a total of $20,000 in gross wages during any calendar quarter in the current or preceding calendar year

Date on which you paid $20,000 in gross wages during a calendar quarter to meet this requirement

Employed ten or more workers for some portion of a day in 20 different calendar weeks during the current or preceding calendar year (all 20 calendar

weeks must occur within the same calendar year)

NOTE: The services do not have to be performed in consecutive weeks or by the same ten employees.

Date on which you first employed ten workers for some portion of a day to meet this requirement

Date on which you employed ten workers for some portion of a day in the 20

calendar week to meet this requirement

Household/Domestic-Services Employer (as defined in CESA 8-70-121)

Paid one or more workers performing domestic services in a private home, local college club, or local chapter of a fraternity or sorority a total of

$1,000 in gross wages during any calendar quarter in the current or preceding calendar year

Date on which you paid one or more workers $1,000 in gross wages during a calendar quarter to meet this requirement

Nonprofit Organization, Including Political Subdivision (exempt under section 501[c][3] of the Internal Revenue Code and as defined in CESA 8-70-118)

Political Subdivision/Government

Had four or more workers employed anywhere in the U.S. in any calendar quarter in the current calendar year or preceding calendar year

NOTE: The services do not have to be performed in consecutive weeks or by the same four employees.

Date on which you first employed at least one worker in Colorado

Date on which you first employed four workers anywhere in the U.S. to meet this requirement

Date on which you employed four workers anywhere in the U.S. in the 20

calendar week to meet this requirement

Type of services provided

18. Has the owner, partner, or corporate officer of this business entity owned or operated any business in Colorado or does the owner, partner, or corporate

officer currently own or operate any other business in Colorado?

Yes

If Yes, provide the information requested below for each business regardless of whether it is still in operation or related to this business entity. In

addition, provide the requested information for all affiliated businesses. Attach additional sheets of paper if necessary.

Legal Business Name

UI Account Number

FEIN

Legal Business Name

UI Account Number

FEIN

UITL-100 Page 3 (R 05/2011)