Ohio Department of Job and Family Services
REPORT TO DETERMINE LIABILITY
Attention: Contribution Section
P.O. Box 182404
Columbus, Ohio 43218-2404
(614) 466-2319 extension 22485
1.a. Employer Name
1.b. Employer Trade name (if any)
1.c. Telephone #
1.d. E-mail Address
1.e. Physical Business Address (street)
1.f. Mailing Address (if different) (street)
Type of business operation:
Limited Liability Company
Corporation (state of inc.)
(date of inc.)
Provide the following information regarding the employer’s principal members (individual, partners, corporate officers, etc.).
(If not sufficient space, attach supplemental sheet.)
3.a. On what date did you begin operations in Ohio?
3.b. On what date did you first employ one or more workers in Ohio?
(include corporate officers)
Was the trade or business previously operated by another employer?
5.a. Have you previously been subject to the Ohio Unemployment
If “Yes” complete JFS 66302
5.b. If yes, provide: (name)
(ODJFS account #)
Provide your federal employer identification # (I.R.S.)
7.a. Have you paid wages which were taxable under the Federal Unemployment Tax Act (FUTA)?
7.b. If yes, indicate which years.
8.a. Is your enterprise exempt from federal income taxes under section
8.b. If yes, attach a copy of the exemption letter issued by the Internal
501 ( c )(3), Internal Revenue Code?
9.a. Describe fully the type of business you operate. Do you have more than one place of business or employment in Ohio?
OHIO county in which workers are
Number of Workers
Nature of business, including services performed
and products manufactured or sold. (If engaged in trade,
indicate retail or wholesale).
9.b. Is the establishment primarily engaged in performing services for other units of the company?
If “YES”, indicate nature of activity:
Central Administrative Office
Research, Development or Testing
Note: If you have any questions regarding question 9.a. or 9.b., please telephone (614) 644-2689.
JFS 66300 (Rev. 4/2010)
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