Form Mdes-13 - Report To Determine Liability For Unemployment Tax - Non-Profit - 2001 Page 2
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2REPORT TO DETERMINE LIABILITY FOR UNEMPLOYMENT TAX (continued)
c c c c c c c - c c c
Write in your Minnesota Unemployment Tax Account Number:
12. INDEPENDENT CONTRACTOR OR EMPLOYEE?
This department renders opinions and issues formal determinations regarding classification of workers.
If you have or contemplate hiring independent contractors check the box to receive information on the
q
SEND
factors considered in making these determinations.
INFORMATION
13. OWNERSHIP INFORMATION:
Please print or type. This report must be signed by authorized officers. Attach additional sheet if needed.
I certify that information on this form is true to the best of my knowledge.
Full Legal Name
Title
SSN
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
Full Legal Name
Title
SSN
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
Full Legal Name
Title
SSN
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
14. Form prepared by:
Phone #
Date
The Purpose of the MDES-13
Information you provide on this form will be used for the purpose of determining your liability to pay into the unemployment fund under
the Minnesota Economic Security Law and other purposes authorized by law. This information is required under Minnesota Statutes
268.043 and 268.186. Information you supply may make you liable for (1) a tax on your payroll if you are a private employer; or (2) the
reimbursement of unemployment benefits paid to your ex-employees if you are a public or nonprofit employer. Not supplying this
information could result in the assessment of taxes, interest and penalties as set forth under Minnesota Statute 268.057. Information
you furnish will be released to the Internal Revenue Service to certify the amount of employment taxes you paid this State for which you
are requesting a credit against the tax imposed by Section 3301 of the Federal Unemployment Tax Act and for such purpose and to
such entities as set forth in Minnesota Statute 268.19.
MDES-13 NON-PROFIT
(rev. 01-01)
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