Form K-Cns 010 - Status Report Unemployment Insurance Liability Determination
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1
2FOR KDOL USE
401 S.W. Topeka Boulevard, Topeka, KS 66603-3182
ACCOUNT NUMBER
BASIS LIA
LIA EFFECTIVE
• Telephone - 785-296-5027 • Fax - 785-291-3425
STATUS REPORT
ESTAB DATE
TYPE OWN
NAICS
Unemployment Insurance Liability Determination
CNTY
LMIS
QTR PRINT REQUEST
L&L
LIQ
PARTIAL
ELEC TRAN
MAN TRAN
NO TRAN
EXAM UNIT
DELNQT ACCNT UNIT
1. When did you first pay wages IN KANSAS? MM-DD-YYYY _______________________________________________________________
2. Your nine digit FEDERAL Employer’s Identification Number (FEIN, TIN) ______________________________________________________
3. To help us assign a more accurate unemployment tax rate and NAICS classification, describe, with some detail your MAJOR KANSAS business activity,
product or service that generates the most revenue. Please include your Internet home page address:_______________________________________________
4. Are you an employee leasing company, PEO, or client?
No
Yes
If Yes, indicate
PEO, or
Client
5. Corporate name:________________________________________________________________________________________________________________________
6. Business or trade name:__________________________________________________________________________________________________________________
IF DIFFERENT THAN CORPORATE NAME
7. Mailing address: __________________________________________________________________________________
________________________________
STREET ADDRESS AND/OR PO BOX
AREA CODE
TELEPHONE
_________________________________________________________________________________________________
CITY
STATE
ZIP PLUS 4
8. KANSAS business location:
Storefront/Physical Location
Job/Construction Site
Employee’s Residence
_________________________________________________________________________________________________
________________________________
STREET ADDRESS (DO NOT USE PO BOX)
CITY
STATE
ZIP + 4
AREA CODE
TELEPHONE
9. Company or In-house payroll contact: ________________________________________________________________
________________________________
NAME
AREA CODE
TELEPHONE
E-mail address: ___________________________________________________________________________________ Fax: ________________________________
USER
AREA CODE
TELEPHONE
Off-site payroll contact: ____________________________________________________________________________
________________________________
NAME
AREA CODE
TELEPHONE
________________________________________
____________________________________________________________________________________________
SERVICE BUREAU/COMPANY
ADDRESS
10. Type of
Individual
Corporation
Limited Liability Company
Government
501(c)(3)
Ownership:
Partnership
Limited Partnership
Limited Liability Partnership
Other – specify___________________________________________
11. Owners – Partners (general & limited) – Corporate Officers – Member/Managers – etc. Use LEGAL names. Do NOT use nicknames.
Social Security No.
First Name
-
Middle Initial
-
Last Name
Title
Date of Birth
Residence Address
K-CNS 010 (Rev. 1-08)
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Parent category: Legal