Form 1a - Agricultural Status Report (2001)
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1
2Utah Department of Workforce Services
DWS-U1
Form 1A
Unemployment Insurance
Rev. 5/01
140 East 300 South
P.O. Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400
FAX (801) 526-9377
AGRICULTURAL STATUS REPORT
READ INSTRUCTIONS ON REVERSE SIDE THEN COMPLETE ALL ITEMS
(TYPE OR PRINT LEGIBLY)
1. Type of Ownership
Individual
Partnership
Corporation
LLC
Other
2. Corporation, trade or business name and mailing address for quarterly contribution (tax) reports:
4. Federal Employer Identification Number (FEIN):
5. County in Utah where
6. Number of permanent
principal activity
worksites employing
is located:
agriculture help:
3. Telephone Number: (
)
Fax Number: (
)
7. Mailing address for Wage and Separation
8. Street address of principal permanent work
9. Street address of business headquarters
Requests (if different from item 2):
site in Utah (if different from items 2, 7, or 9):
(if different from item 2):
10. List sole proprietor, general partners, corporate officers or LLC members:
Name
SSN
Title
Home/Address
Home Phone
(
)
(
)
(
)
11. Describe in detail the type of agricultural employment: (see instructions on reverse side)
12. Date of first payment of wages in Utah:
READ INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING ITEMS 13-13e
13. Did you acquire the organization, trade, or business of another operator?
Yes
No
Type of acquisition:
Change of ownership
Merger or reorganization
Sale, lease or sub-lease
Purchased assets through court
Other, please explain:
13a. Name, address and UI account number (if available) of previous owner (predecessor):
#
Date acquired
13b. Did you acquire all or a portion of the predecessor’s organization, trade or business?
90% or more
Less than 90%
13c. Did you retain all of the predecessor’s employees?
Yes
No
13d. Is your predecessor still in business?
Yes
No
13e. Was predecessor’s business closed prior to acquisition?
Yes
No
Date closed ________________
14. Enter below the amount of wages you have paid in Utah. If you have not paid wages enter “NONE.”
Jan. 1 to Mar. 31
Apr. 1 to Jun. 30
Jul. 1 to Sep. 30
Oct. 1 to Dec. 31
Current
Year:
Preceding
Year:
15. If you have not paid wages, do you expect to in the future?
Yes
No Estimated date _____________________
16. Do you have 10 or more employees during 20 different weeks in the current or preceding year? (See instructions)
Yes
No - If yes show quarter ending date ____________________________________________
17. Do you have additional agricultural payroll in a state other than Utah? (If yes, refer to instructions on reverse side.)
I certify that the information contained in this report is true and correct.
(
)
Name
Title
Telephone Number
Date
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