Report New Client/of Termination
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1UI Tax and Wage Administration P.O. Box 9046 Olympia, WA 98507-9046 Fax: (360) 902-9264
REPORT NEW CLIENT
REPORT OF TERMINATION
(check one)
All fields are mandatory
This is to inform the Washington State Employment Security Department that the professional employer organization
(PEO) and the client named below signed an agreement and entered into or terminated a co-employer relationship.
termination (check one) date of this agreement is: __________________.
The
effective /
PEO Employment Security Reference #:
CLIENT Employment Security Reference #:
Name:
Name:
D.B.A.:
D.B.A.:
Address:
Address:
City, St, Zip:
City, St, Zip:
E-mail:
E-mail:
F.E.I.N.:
UBI#:
F.E.I.N.:
UBI#:
Contact:
Phone:
Phone:
Date employees first hired in Washington:
CLIENT INFORMATION
Sole Proprietorship
Partnership
S Corporation
Corporation
Type of business:
Nonprofit
Government
Fiduciary / Trust
Limited Liability Company
Other:
Washington location where payroll and business records will be available for inspection:
Client Records Contact Name:
_________________________________________________
Street Address:
_________________________________________________
City, State, Zip:
_________________________________________________
Phone:
_________________________________________________
List owners, corporate officers, partners or LLC members (attach additional sheet if necessary):
Name
SSN
Name
SSN
Fill out this form, print and return to us. Mail: Employment Security Department, Attn: Status Unit, PO Box 9046,
Olympia, WA 98507-9046; Fax: 360-902-9264. If you are reporting a new client, you must include a completed
power-of-attorney
form. The form is also available through your
district tax office
.
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