Form Uitl-100 - Application For Unemployment Insurance Account May 2011 Page 4

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19. Will the business entity file a consolidated federal tax return, including Internal Revenue Service Form 851, with any other business or entity?

Yes

If Yes, provide the information requested below for each business or entity included in the consolidated tax return. Attach additional sheets of paper

if necessary.

Legal Business Name

UI Account Number

FEIN

Legal Business Name

UI Account Number

FEIN

20. Is this business entity the result of a reorganization of a previously existing business entity or entities?

Yes

If Yes, provide the information requested below for all business entities. Attach additional sheets of paper if necessary.

NOTE: Attach a copy of your reorganization plan. Provide the names of all corporate officers for all entities, a statement explaining the reason for the

reorganization, and any cost-benefit analysis that was completed in relation to the reorganization.

Legal Business Name

UI Account Number

FEIN

Legal Business Name

UI Account Number

FEIN

21. Was this business entity purchased as a franchise from a corporation or franchisor?

Yes

Was this business entity purchased as a franchise from a corporation or franchisee?

Yes

22. Please provide additional information or comments in the space provided below. If you are providing information relative to a question above, please note

the question number.

Information/Comments

I certify under penalty of perjury that the above information is true, accurate, and complete to the best of my knowledge. I understand that there are severe

penalties for providing false statements and willfully misrepresenting information in order to reduce UI rates.

Name of Company Officer (please print)

Title

Telephone Number

Alternate Telephone Number

E-mail Address

Signature of Company Officer

Date

The completion of this application is for UI purposes only. If you need to register your business in Colorado for other purposes such as establishing wage

withholding, applying for a state sales tax license, or registering a trade name, complete Form CR 0100, Colorado Business Registration. The Colorado

Business Registration is available at

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UITL-100 Page 4 (05/2011)