Form Sfn 41216 - Report To Determine Liability
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4Job Service Use
REPORT TO DETERMINE LIABILITY
EAN
JOB SERVICE NORTH DAKOTA
UNEMPLOYMENT INSURANCE
ST
SFN 41216 (R. 7-2014)
RE
BY
FR
RA
YR
-1
UI TAX AND FIELD SERVICES
PO BOX 5507
-2
Q
STF
BISMARCK NORTH DAKOTA 58506- 5507
SIC
AUX
701-328-2814
FAX: 701-328-1882
TTY RELAY ND 800-366-6888
NAIC
AUX
LOC
OWN
Web link to:
NEW BUSINESS REGISTRATIONS IN NORTH DAKOTA
1. Business Name
3. Telephone Number
2. Corporate or Legal Name
4. Federal Employer ID (FEIN)
5. Mail Address (Number and Street or P.O. Box) City
State
ZIP Code + 4
Internet Address (optional)
6. Street Address (Number and Street)
City
State
ZIP Code + 4
E-mail Address (optional)
7. Is (Are) any other business(es) being operated
If yes, Name of Business(es)
in North Dakota by this ownership?
Yes
No
8. Type of Ownership
Individual
Partnership (Indicate type: general, LP, LLP, etc.)
Click to obtain SFN 18411
Corporation
Limited Liability Company (LLC) (Indicate treatment for federal income tax reporting):
if you wish to exempt Corp Officer services
Nonprofit Corporation
Disregarded Entity
Partnership
Corporation
S-Corp
Don't Know
Government
Cooperative
Indian Tribe or Wholly-Owned
Other (Describe)
Entity of an Indian Tribe
In what state was your business originally incorporated/registered?
Date
9.
List the owner(s) and all partners or corporate officers. Also, any corporate director or employee having a 20 percent or more ownership
interest. Attach separate sheet if necessary.
Social Security
Percent
Name
Home Address
Number*
Owner
Title
* In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or
North Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax,
program eligibility purposes and program performance accountability.
10. Have you employed workers in North Dakota?
If yes, date you first employed workers in North Dakota
Yes
No
If you are a government entity, Indian tribe, or wholly-owned entity of an Indian tribe, go to Question 17.
11. Did you acquire any part of the ND assets or business of another employer or change your business status/structure in any way?
If yes, complete Schedule B.
Yes
No
12. Are you liable for federal unemployment taxes (FUTA)?
If yes, go to Question 18. You will be covered under North Dakota law as of the first day you
Yes
No
Don't Know
employ workers in this state.
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