Certification Of Subcontractor'S Unemployment Insurance Payments Form - Detr

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Employment Security Division
Contributions Section
*0*
500 East Third Street
Carson City, NV 89713-0030
0
(775) 684-6300
CERTIFICATION OF SUBCONTRACTOR'S UNEMPLOYMENT INSURANCE PAYMENTS
INSTRUCTIONS: Prime (general) contractors are responsible for having Sections I and II completed and returned to the Employment Security
Division.
SECTION I. SUBCONTRACTOR:
ESD Employer
Account No. ______________
Federal Employer Identification No. ____________________
Name: ________________________________
Address: __________________________,_____________________
Names(s) and location(s) of ALL Nevada contract(s):
I hereby authorize the release of information of my financial obligations to the Nevada Employment Security Division to the below
named prime (general) contractor:
__________________________________________________
_______________________________________
Signature of Subcontractor or Authorized Representative
Print Name and Title of Subcontractor
Telephone _______________________
FAX _______________________
Date _________________________
SECTION II. PRIME (GENERAL) CONTRACTOR:
ESD Employer
Account No. ________________________
Name ________________________________________________
Certification of quarter ending ________________________
Date subcontract commenced __________________________
Date of last progress payment in this subcontract ___________________
Date subcontract completed _____________________
I certify that the above contract(s)
has
has not been completed and do hereby request certification of the above
subcontractor's financial obligation to the Nevada Employment Security Division.
__________________________________________________
________________________________________
Signature of Prime (General) or Authorized Representative
Print Name and Title of Prime (General) Contractor
Telephone ___________________________
FAX _______________________
Date _________________________
NOTE: If the prime (general) contractor fails to withhold sufficient money on the contract or require a good and sufficient surety bond
from all subcontractors, the prime (general) contractor may be held directly liable for the subcontractor's unpaid unemployment insurance
contributions, penalties, and interest with respect to wages paid on the contract. (NRS 612.687)
SECTION III. EMPLOYMENT SECURITY DIVISION:
I certify that the above named contractor has filed all required wage reports and has paid all known contributions, penalties, and
interest due the Nevada Employment Security Division through the quarter ended _______________. Such contributions, penalties, and
interest have been paid on unverified wage reports submitted by the above named subcontractor. The prime (general) contractor is
not relieved of any liability from unreported wages with respect to this contract.
I certify that the above named subcontractor has not filed all required wage reports or has not paid all known contributions, penalties,
and interest due the Nevada Employment Security Division through the quarter ended ________________.
NOTE: The prime (general) contractor may be held liable for contributions, penalties, and interest due with respect to this
contract. If a surety bond was obtained, please forward a copy to the Employment Security Division.
The subcontractor is not registered, as shown above, with the Nevada Employment Security Division.
The subcontractor's account was suspended.
The subcontractor's account was deleted.
The subcontractor's account was a "no payroll report" was filed affecting the quarter requested.
Information indicates the subcontractor hired leased employees. The prime (general) contractor is not liable for leased employees.
ESD Manager, Nevada Employment Security Division
Date
*RPT5098*
UI
Report suspected UI Fraud online at or
FRAUD
call (775) 684-0475
RPT5098

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