Form De 1gs - Registration Form For Governmental Organizations, Public Schools, & Indian Tribes - 2001

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This form will be the basic record of YOUR
EMPLOYMENT DEVELOPMENT DEPARTMENT
ACCOUNT. DO NOT FILE THIS FORM UNTIL
ACCOUNT SERVICES GROUP, MIC 28
YOU HAVE PAID WAGES THAT EXCEED
P.O. BOX 826880
$100.00. Please read the INSTRUCTIONS on the
SACRAMENTO CA 94280-0001
back before completing this form. PLEASE PRINT
(916) 654-7041 / FAX 654-9211
OR TYPE. Return this form to:
REGISTRATION FORM FOR GOVERNMENTAL ORGANIZATIONS, PUBLIC SCHOOLS, & INDIAN TRIBES
D
ACCOUNT NUMBER
QUARTER
ETCSO
FED CODE
ON-LINE PROCESS DATE
TAS CODE
E
P
T
U
S
E
OWNERSHIP BEGAN OPERATING
FEDERAL I.D. NUMBER
A.
BUSINESS NAME
MONTH:
DAY:
YEAR:
B.
NATURE OF ACTIVITY
ORGANIZATION OR TRIBE NAME
List all principal officers or administrators
TITLE
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER
CITY OR TOWN
STATE
ZIP CODE
COUNTY
C.
BUSINESS LOCATION Street and Number (see instructions)
FAX NUMBER:
E-MAIL ADDRESS:
)
CITY OR TOWN
STATE
ZIP CODE
PHONE NUMBER
MAILING ADDRESS (in care of P.O. Box or Street and Number
(
)
D.
HAVE YOU EVER BEEN REGISTERED WITH
IF YES, ENTER EMPLOYER ACCOUNT NUMBER, BUSINESS NAME AND ADDRESS
THE DEPARTMENT?
ACCOUNT NUMBER
BUSINESS NAME
ADDRESS
PHONE NO.
(
)
No
Yes
E.
F.
INDICATE FIRST QUARTER AND YEAR IN WHICH YOU PAID WAGES.
WILL YOU BE SUBJECT TO FEDERAL MONTHLY/SEMI-
WEEKLY DEPOSITS?
Jan.-Mar. 20___
Apr.-June 20___
July-Sept. 20___
Oct.-Dec. 20___
No
Yes
G.
H.
ORGANIZATION TYPE
WOULD YOU LIKE INFORMATION ON THE FOLLOWING
ALTERNATIVE UNEMPLOYMENT INSURANCE FINANCING?
(SD) SCHOOL DISTRICT
(IT) INDIAN TRIBE
No
Cost of Benefits
School Employees Fund
(GO) GOVERNMENTAL
(OT) OTHER (Specify) __________________
Yes
Election of Disability Coverage
I.
NUMBER OF
EMPLOYER TYPE
EMPLOYEES
(07) Public School
(11) Indian Tribe
(15) State Colleges
(21) Public Entity
(28) State Hospital
(08) District Hospital
(14) University of CA
(16) District Fair
(26) Fed-State Withholdings
J.
CONTACT PERSON FOR BUSINESS
NAME
TITLE
ADDRESS
PHONE
(
)
K.
SUPPORTIVE SERVICES
If you are part of a larger organization and you are primarily engaged in providing supportive services to other establishments of the larger
organization, check one of these boxes.
(1)
Control Administrative (headquarters, etc.)
(3)
Storage (warehouse)
(5)
Does not apply
(2)
Research, development, or testing
(4)
Other (specify)______________________________________________
L.
DECLARATION
These Statements are hereby declared to be correct to the best knowledge and belief of the undersigned.
(
)
Signature
Date
Residence Phone
Title
Residence Address
(Officer, Administrator, etc.)
Street
City
State
ZIP Code
DE 1GS Rev. 4 (10-01) (INTERNET)
Page 1 of 3
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