Form Uct-5334-E - Agricultural Employer'S Report For 2017
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Complete 1-21
AGRICULTURAL
EMPLOYER'S REPORT FOR 2017
1.
Legal Name
Required to determine your employer status under the Wisconsin
2.
Trade Name (DBA)
Unemployment Insurance Act, (CHAPTER 108, WIS. STATS.) COMPLETE
AND RETURN THIS REPORT WITHIN 10 DAYS UNLESS INSTRUCTED
3.
Mailing Address c/o (
if required for correct delivery)
OTHERWISE.
4.
Street or P.O. Box
UI ACCOUNT NUMBER
5.
City
State
Zip Code
6.
Federal Identification Number
7.
Person To Contact For Additional Information
Name
Department of Workforce Development
Send to:
Division of Unemployment Insurance
Email Address
P.O. Box 7942
Madison, WI 53707
Telephone Number
Telephone: (608) 261-6700
14. Do you continue to have paid agricultural
Fax: (608) 267-1400
employees working in Wisconsin?
Yes
No
email: taxnet@dwd.wisconsin.gov
If no, give date of last employment (mm/dd/yyyy)
8.
Check Type of Ownership:
Limited Liability Company
Are you presently out of business?
Individual
- State of Registration:
Yes
No
Partnership
Limited Liability Company Electing to be
Did you sell or transfer your business?
Treated as a Corp for Federal Tax
Yes
No
Purposes. You must submit a copy of
Corporation
your IRS Notice of Acceptance
- State of Incorporation:
- State of Registration:
If you sold or transferred your operation,
provide:
Other (Estate, Trust,
Limited Liability Partnership
Date you sold or transferred your operation
Receivership)
(mm/dd/yyyy)
-State of Registration:
- Identify:
Legal name of new owner you sold /transferred to
Limited Partnership
9.
Provide Name(s) and Social Security Number(s) of Individual, Partners, or
Street Address or P.O. Box of new owner
Corporate Officers (Include Middle Initial):
Names(s)
S.S No.(s)
City
State
Zip code
10. Briefly describe type of agricultural operation:
15. Do you currently have any business activity
covered under the Wisconsin UI law
Yes
No
If yes, provide:
11. Identify the TOWN and COUNTY in Wisconsin where your operation is located:
Business Name
12. Date you first had agricultural employees in Wisconsin (mm/dd/yyyy)
UI Account Number
13. Did you acquire all or part of an already established agricultural business?
16. Have you ever had 10 agricultural employees
working for you on the same day?
Yes
No
If yes, provide:
Yes
No
Date of Acquisition (mm/dd/yyyy)
Have you ever paid $20,000 in cash wages for
agricultural labor in a single calendar quarter?
Legal Name of Prior Owner
UI Account Number of Prior Owner
Yes
No
Current Address of Prior Owner
If you answered 'yes' to either question, continue
to 17.
City
State
Zip code
If you answered 'no' to both questions, continue to
19.
UCT-5334-E (R. 01/2017)
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Parent category: Business