Employer Status Report Form Page 2
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311a.
Please provide the name and address of prior owner.
11b.
Check (x) the type of change:
Reorganization
Purchase Assets of business
Transfer of trade of business
Merger
Change of entity (e.g. proprietorship to corporation)
Lease of business
Transfer of workforce (employees) If checked, must complete Trade, Business, and Workforce Transfer Report.
11c.
Were there any business assets not acquired?
Yes
No
If yes, list business assets not acquired:
11d.
Will the prior owner remain in business in NH?
Yes
No
If yes, please explain:
12.
Enter the gross payroll of your business for the current and two prior calendar years. (New Hampshire Payroll Only)
Calendar Year
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
$
$
$
$
$
$
$
$
$
$
$
$
13.
Do you expect to have a gross payroll of at least $1,500 in a calendar quarter?
Yes Enter the earliest quarter and year this occurred (or will occur)
No
If No, have you or do you expect to employ at least one worker in 20 different weeks in a calendar year?
If so, when did this occur (or will occur)?
14.
Enter by week the number of workers to whom you furnished employment in New Hampshire. Show current calendar year employment first,
followed by employment in all preceding calendar years. Note: A week is seven consecutive calendar days beginning at 12:01 am Sunday and
ending at 12:00 midnight on the next succeeding Saturday. (Emp 101.01)
CALENDAR YEAR: ___________
CALENDAR YEAR: ___________
CALENDAR YEAR: ___________
1st
2nd
3rd
4th
5th
1st
2nd
3rd
4th
5th
1st
2nd
3rd
4th
5th
JAN
JAN
JAN
FEB
FEB
FEB
MAR
MAR
MAR
APR
APR
APR
MAY
MAY
MAY
JUN
JUN
JUN
JUL
JUL
JUL
AUG
AUG
AUG
SEP
SEP
SEP
OCT
OCT
OCT
NOV
NOV
NOV
DEC
DEC
DEC
15.
In addition to the employment shown under item 14, did you engage any “self employed individuals”, “sub-contractors”, consultants”, etc?
No
Yes, furnish name, trade, and address below (use block 19 or a separate sheet if necessary)
Domestic-Household Employment Section
16.
Have you had or do you expect to have a $1,000 quarterly payroll for domestic service?
Yes
No
If Yes, give the earliest quarter and year this occurred (or will occur). Quarter ________ Year _________
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