Form Uct-43-E - Preliminary Report - 2017
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2This is a fill-in form. Please click on the appropriate are to enter information. Tab between fields and PRINT when completed.
Complete 1-23.
PRELIMINARY 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
Department of Workforce Development
6.
Federal Identification Number
Send to:
Division of Unemployment Insurance
7.
Person To Contact For Additional Information:
P.O. Box 7942
Name
Madison, WI 53707
Email Address
Telephone (608) 261-6700
Fax: (608) 267-1400
Telephone Number
email: taxnet@dwd.wisconsin.gov
12. Nature of Business in Wisconsin
8.
Check Type of Ownership:
Individual
Limited Liability Company
Partnership
State of Registration
Corporation
Limited Liability Company Electing to
State of Incorporation:
be Treated as a Corp for Federal Tax
Other (Estate, Trust,
13. Did you acquire any portion of an already
Purposes. You must submit a copy of
Receivership)
your IRS Notice of Acceptance
established Wisconsin business?
Identify:
State of Registration
Limited Liability Partnership
Yes
No
If yes, provide:
State of Registration
Limited Partnership
9.
Provide Name(s) and Social Security Numbers(s) of Sole Owner, Partners,
Date of Acquisition (mm/dd/yyyy)
Members, or Corporate Officers
Names(s)
S.S No.(s)
Legal Name of Prior Owner
UI Account Number of Prior Owner
10. Wisconsin Employment Began (mm/dd/yyyy):
Trade Name of Prior Owner:
11. Location of Wisconsin activity:
Current Address of Prior Owner
Street address
City
State
Zip
City
State
Zip
. In the table below show WISCONSIN payroll and number of employees to date. Include ONLY individuals hired for work
14
exclusively or generally in WISCONSIN whether they are Wisconsin or out-of-state residents. Also, include any employee
whose services have become localized in Wisconsin upon transfer to Wisconsin employment. Do not include wages paid to
persons from COMMON PERMITTED EXCLUSIONS listed on page 4.
2015
2016
2017
QTR
Gross Payroll
No. of Employees
Gross Payroll
No. of Employees
Gross Payroll
No. of Employees
1st
2nd
3rd
4th
COMPLETE THE SECOND PAGE OF THIS REPORT
UCT-43-E (R. 01/2017)
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Parent category: Business