Form Des-100a - Employer Status Report - 2007 Page 3
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317.
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 NO.
RESIDENT ADDRESS
TITLE
SIGNATURE
DATE
NAME (Type or Print)
SOCIAL SECURITY NO.
RESIDENT ADDRESS
TITLE
�
SIGNATURE
DATE
NAME (Type or Print)
SOCIAL SECURITY NO.
RESIDENT ADDRESS
TITLE
SIGNATURE
DATE
19. Remarks
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