Employer Status Report Form
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2
3(Do not write in this space)
Account #
Subject
Retroactive
Successor
32 South Main Street
Acquisition
Concord, New Hampshire 03301-4857
Not Subject
Phone (603) 224-3311
Fax (603) 229-4323
NAICS
EMPLOYER STATUS REPORT
PLEASE READ INSTRUCTIONS THEN COMPLETE ALL ITEMS (TYPE OR PRINT LEGIBLY)
To establish its status under the provisions of the New Hampshire Unemployment Compensation Law, each employing unit is
required by the law to file with this department an Employer Status Report (RSA 282-A).
1.
2.
Federal Identification Number
-
BUSINESS NAME OR TRADE NAME
3.
Describe in detail your principle activity
in NH.
ADDRESS OF PRINCIPLE PLACE OF BUSINESS IN NH (Do NOT use post office box).
If more than one location, attach a separate sheet and list all.
CITY
STATE
ZIP CODE
3a. Describe in detail your principle products,
processes, or services in NH.
PHONE NUMBER
FAX NUMBER
E-MAIL
4.
Check (x) type of business
Sole Proprietorship
MAILING ADDRESS IF DIFFERENT FROM ABOVE
Partnership
STREET ADDRESS OR POST OFFICE BOX
Corporation
LLC (Single member)
CITY
STATE
ZIP CODE
LLC (Partnership)
PHONE NUMBER
FAX NUMBER
LLC (Corporation)
5.
If a corporation or LLC, enter the following: Date of Registration
/
/
State of Registration
Full corporate or LLC name:
6.
Is your business a nonprofit organization described in Section 501(c)(3) and exempt under 501(a) of the Internal Revenue Code?
Yes
No
If Yes, attach a copy of your letter of exemption.
7.
Enter date on which employment was first furnished in New Hampshire
/
/
Enter date wages were first paid in New Hampshire
/
/
8.
Ceased to furnish employment in NH on
/
/
Reason:
9.
Are or will you be subject to the Federal Unemployment Tax Act in the current year?
Yes
No
10.
Has employment been furnished in NH in preceding years during which you were subject to the Federal Unemployment Tax Law?
No
Yes,
list years:
11.
Did you acquire the organization, trade, business, workforce, or any of the New Hampshire assets of any other employing unit
or employer?
Yes
If Yes, date of acquisition:
/
/
, % of assets acquired
, then complete questions 11a thru 11d.
No
If No, skip to item 12.
DES-100A R-7/07
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