Form Nhes 0037 - Employer Status Report - 2013 Page 2
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211b.
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 as 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 in 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 _________
17.
If this report is prepared by other than a sole proprietor, this item must be completed.
I (we) declare under the pains and penalties of perjury that I (we) prepared this report for the employing unit named herein and that this report,
including any accompanying schedules and statements, is to the best of my (our) knowledge and belief, a true, correct, and complete report based
on all the information relating to the matters required to be reported in this report of which I (we) have any knowledge.
NAME
FIRM NAME
DATE
SIGNATURE
ADDRESS
PHONE
18.
This report must be signed by owner, all partners, authorized corporation officers.
It is hereby certified that the information in this report, including any attached sheets, is true and correct to the best of my (our) knowledge and
belief and is signed under the pains and penalties of perjury.
Name (Type or Print)
Social Security Number
Resident Address
Title
Signature
19.
Remarks
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