Form Lb-0443 - Report To Determine Status State And Local Government
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1
2TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
REPORT TO DETERMINE STATUS
DIVISION OF EMPLOYMENT SECURITY
STATE AND LOCAL GOVERNMENT
EMPLOYER ACCOUNTS/EMPLOYER SERVICES
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE TN 37243
(615)741-2486
Fax (615)741-7214
OFFICIAL USE ONLY
Tennessee ID Number
M. No.
County
Alt Zip
1. Federal No. ___ ___ - ___ ___ ___ ___ ___ ___ ___
Liab.
Org.
First Employment
Date Liable
Employer Name
______________________________________________
Comp Year
ROC
VERIFIED
NAICS
M-NAICS
Mailing Address
______________________________________________
Previous No.
Rate
________________________________________
______________________________________________
________________________________________
______________________________________________
PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:
Phone __________________________
______________________________________________
Fax
__________________________
______________________________________________
EMail Address ____________________________________
______________________________________________
______________________________________________
Business Website _________________________________
Note: Attach copy of Public Act creating your governmental organization.
2. (a) Type of governmental entity:
State Government
Local Government
(b) List below all state or local governmental agencies or departments that will report under this account number.
Agency or Department
Address
County
Nature of Service
Number of
Employees
Attach list if additional space is needed.
(c) Name and Title of three (3) principal officers or officials:
(1) Name
(2) Name
(3) Name
(1) Title
(2) Title
(3) Title
3. Name of person responsible for payroll records ______________________________
Phone Number _____________________
4. Date your governmental entity first had employees in Tennessee ________________
5. Does your governmental entity elect to reimburse the Department of Labor and Workforce Development for benefits paid in lieu of paying
premiums?
YES
NO
If answer is YES complete Reimbursement Election on page 2 of this form. (See Page 2.)
NOTE: Reimbursing employers are liable for all benefits based on wages paid by them including overpayments due to administrative
errors or improper employer reporting.
THIS REPORT MUST BE SIGNED BY AN AUTHORIZED OFFICIAL.
DATE
SIGNATURE
TITLE
LB-0443 (Rev. 02-15)
RDA 1559
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Parent category: Legal