Form Conn. Uc-1 Mun - Employer Status Report For Unemployment Compensation
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1Registration Number
ABC Over 6
Lag Date
FORM CONN. UC-1 MUN (Rev. 4/10)
EMPLOYER STATUS REPORT
FOR OFFICE USE ONLY
COMPENSATION
IC
Under 6
_________
for UNEMPLOYMENT OMPENSATION
Status _________________________________
8
9
FUND CODE
Rate(s)_________________________________
Typed 2PS
___________
Quarter(s)_______________________________
OTHER__________________
Predecessor Reg No.
Date Rec=d_______________________________
_________________________
RETURN COMPLETED FORM TO:
FOR THE STATE OF CONNECTICUT OR ITS MUNICIPALITIES
Form is to be typed or printed in ink. If additional space is required, please attach
EMPLOYER STATUS UNIT
extra sheet. Indicate company name at the top of the sheet and include
200 FOLLY BROOK BLVD.
respective item number with response.
WETHERSFIELD, CT 06109-1114TEL NO.
TEL NO. (860) 263-6550 FAX (860) 263-6567
(860) 263-6550
FAX (860) 263-6567
1. Federal Identification Number___________________ Tel. No. (
)______________Email address:__________________________________
2. Business or Trade Name ________________________________________________________________________________________________
3. Name of Owner, Partners, or
Corporate name, if other than above_______________________________________________________________________________________
4. Mailing
address ______________________________________________________________________________________________________________
Number
Street or P.O. Box
City
State
Zip Code
5. List all Connecticut business locations, if different from above. If mailing address is P.O. Box, please give the physical
location of business.
___________________________________________________________________________________________________________
6. Are you a political or governmental subdivision of this state, including any regional school board, Board of regents, social service or
welfare agency, public or quasi-public corporation, housing authority, parking authority, or other authority or public agency established by
law, and any water district, sewer district, or similar authority established by special act or existing under the general statutes of this state?
Yes If AYES@, please complete item 6a.
If ANO@ , please explain.
No
a. Entities, determined to be liable, have the option of reimbursing the Connecticut Unemployment Compensation Fund for
unemployment compensation benefits paid former employees, or paying the regular State Unemployment Compensation Tax. Please indicate
your option below.
Reimbursement of benefits paid method
Regular quarterly tax method
7. How many employees do you have in Connecticut at the present time? _________________________
8. When did you first engage employees in Connecticut? _________________________________________________________
Month
Day
Year
9. Purposes for which you organized and operate ________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
10. Under what legal authority is this entity established?____________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I affirm that I have read the questions and the answers are true to the best of my knowledge and belief.
Signature of Principal Administrative Official
Title
Date
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