JT-1/UC-001 (5/15)
Page 3
Section D: Withholding/Unemployment Tax Information
1. Date Employees
2. Are you liable for Federal Unemployment Tax?
3. Are individuals performing services that are excluded from
withholding or unemployment tax?
*
First Hired in Arizona.
o
o
Yes
If yes, what was the first year of liability?
Yes
If yes, describe the services:
o
No
Year
o
No
4. Do you have an IRS Ruling that grants an exclusion
5. Do you have or have you previously had an Arizona Unemployment Tax Number?
from Federal Unemployment Tax?
o
No
o
Yes
If yes, attach a copy of the Ruling Letter.
o
Yes
If yes, Business Name
o
No
Unemployment Number
6. Record of Arizona wages paid by calendar quarter for current and preceding calendar year.
YEAR
1ST QUARTER
2ND QUARTER
3RD QUARTER
4TH QUARTER
7. Weekly record of number of persons performing services in Arizona for current and preceding calendar year.
YEAR
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
YEAR
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Complete this section if you acquired, or changed the legal form of business of, all or part of an existing Arizona business.
*
*
9. Acquired, or Changed Legal Form of Business of,
10. Acquired by
8. Date Acquired or Date
If other, including change
Legal Form of Business
in legal form of business,
o
All
o
Purchase
*
changed
explain:
o
Part
If part, to obtain an unemployment tax rate based on the business’s
o
Lease
previous account you must request it no later than 180 days after
o
Other
the date entered in item 8 of this section. See instructions.
Previous Owner Information or Previous Legal Form of Business Information (See instructions.)
*
*
11. Name(s) of Previous Owner(s)
12. Business Name of Previous Owner(s)
13. Current Mailing Address of Previous Owner(s) (Street, City, State, ZIP code)
14. Current Telephone Number of Previous Owner(s)
15. Unemployment Account Number of Previous Owner(s)
(
)
Voluntary Election of Unemployment Insurance Coverage (subject to Unemployment Tax Office approval).
16. The applicant, on behalf of the employing unit, voluntarily elects beginning January 1 of the current calendar year or the date employment started, if later, and
continuing for not less than two calendar years, to:
o
A. Be deemed an employer subject to Title 23, Chapter 4, Arizona Revised Statutes, to the same extent as all other such employers and provide
unemployment insurance coverage to my workers performing services defined by law as employment, even though I have not met conditions
requiring me to provide such coverage.
o
B. Extend unemployment insurance coverage to workers referred to in item 2, above, by having the services they perform be deemed to constitute.
Employment by an employer subject to Title 23, Chapter 4, A.R.S.
ADOR 10194 (5/15)