Form De 1p - Registration Form For Employers Depositing Only Personal Income Tax Withholding - Employment Development Department Of Michigan

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This form will be the basic record of YOUR
(916) 654-7041 / fax (916) 654-9211
ACCOUNT. DO NOT FILE THIS FORM UNTIL
EMPLOYMENT DEVELOPMENT DEPARTMENT
YOU HAVE PAID WAGES THAT EXCEED
ACCOUNT SERVICES GROUP, MIC 28
$100.00. Please read the INSTRUCTIONS on the
P.O. BOX 826880
back before completing this form. PLEASE PRINT
SACRAMENTO CA 94280-0001
OR TYPE. Return this form to:
REGISTRATION FORM FOR EMPLOYERS DEPOSITING ONLY PERSONAL INCOME TAX WITHHOLDING
D
ACCOUNT NUMBER
QUARTER
ETCSO
FED CODE
ON-LINE PROCESS DATE
TAS CODE
E
P
T
U
S
E
A.
OWNERSHIP BEGAN OPERATING
FEDERAL I.D. NUMBER
BUSINESS NAME
MONTH:
DAY:
YEAR:
B.
SSA NO./CORP/OR LLC I.D. NO.
DRIVER’S LICENSE NUMBER
OWNER, CORPORATION, OR LIMITED LIABILITY COMPANY (LLC) NAME
List all partners, corporate officers or LLC
TITLE
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER
members, managers or officers, etc.*
(partner, officer, LLC member, LLC manager)
*If entity is a Limited Partnership, indicate General Partners with an (*). If needed, list additional partners, LLC members or officers on a separate sheet.
C.
CITY OR TOWN
STATE
ZIP CODE
COUNTY
BUSINESS LOCATION Street and Number (see instructions)
FAX NUMBER:
E-MAIL ADDRESS:
MAILING ADDRESS (in care of P.O. Box or Street and Number)
CITY OR TOWN
STATE
ZIP CODE
PHONE NUMBER
(
)
D.
IF YES, ENTER EMPLOYER ACCOUNT NUMBER, BUSINESS NAME AND ADDRESS
HAVE YOU EVER BEEN REGISTERED WITH
ACCOUNT NUMBER
BUSINESS NAME
ADDRESS
THE DEPARTMENT?
No
Yes
E.
F.
INDICATE FIRST QUARTER AND YEAR IN WHICH INCOME TAX IS WITHHELD.
WILL YOU BE SUBJECT TO FEDERAL MONTHLY/SEMI-
Jan.-Mar. 20__
Apr.-June 20__
July-Sept. 20__
Oct.-Dec. 20__
WEEKLY DEPOSITS?
No
Yes
G.
ORGANIZATION TYPE
(IN) Individual Owner
(JV) Joint Venture
(LQ) Liquidation
(LLC) Limited Liability Company
(HW) Hus/Wife Co-Ownership
(RC) Receivership
(LP) Limited Partnership
(GO) Governmental
(GP) General Partnership
(BK) Bankruptcy
(TR) Trusteeship
(SD) School District
(CP) Corporation
(AS) Association
(EA) Estate Administration
(OT) Other (specify)
H.
EMPLOYER TYPE:
(04) Non Profit School
(09) Agriculture
(20) Red Cross
NUMBER OF
(01) Commercial
(07) Public School
(10) Church or Religious Orders
(21) Public Entity
EMPLOYEES
(02) Non Profit
(08) District Hospital
(12) Annuitant Payer
(28) State Hospital
(03) Non Profit 501 C3
(32) Pay Agent (SEE ADDITIONAL INSTRUCTIONS ON BACK)
I.
1) Please describe the type of product or service your company
BUSINESS TYPE:
provides:
(81) Other Services (Not Public Admin.)
(51) Publication & Communication
(48) Transportation & Warehousing
(42) Wholesale Trade
(72) Accommodation & Food Services
(52) Finance & Insurance
(55) Management of Companies & Enterprises
(31) Manufacturing
(54) Professional, Scientific & Technical Services
(61) Educational Services
2) If MANUFACTURING, please provide a detailed description
(56) Administrative & Support, Waste
(92) Public Administration
of your products and their production processes:
Management & Remediation
(11) Forestry, Fishing & Hunting
(21) Mining
(62) Health Care & Social Assistance
(22) Utilities
(53) Real Estate, Rental & Leasing
(23) Construction
(71) Arts, Entertainment & Recreation
(44) Retail Trade
J.
CONTACT PERSON FOR BUSINESS
NAME
TITLE
ADDRESS
PHONE
(
)
K. Is this a(n):
New business
On-going business just purchased (
All
Part)
Other ________________________
Change of partner(s)
Change in form -
(Sole proprietor to partnership; partnership to corporation; partnership to LLC merger; etc.)
IF THE BUSINESS WAS PREVIOUSLY OWNED, PROVIDE THE FOLLOWING INFORMATION:
Previous Owner
Business Name
Purchase Price
Date of Transfer
EDD Account Number
L.
DECLARATION
These Statements are hereby declared to be correct to the best knowledge and belief of the undersigned.
Signature
Date
Residence Phone (
)
Title
Residence Address
(Owner, Partner, Corporate Officer, LLC Member,
Street
City
State
ZIP Code
LLC Officer, etc.)
DE 1P Rev. 5 (6-01) (INTERNET)
Page 1 of 3
CU

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