Form 1110-A - Employer Status Report
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3FOR DIVISION USE ONLY
Emp. No.:
Subj. Date:
Reason:
Qtr.:
13th Wk.:
No. Employees:
Area:
Ind.:
Rate Yr:
NAICS:
Aux:
EMPLOYER STATUS REPORT
Org.:
Workforce Training
Contribution
Complete And Return This Form Within 10 days To:
Deter. By:
Yr./Rate
Yr./Rate
Status Department - 5th Floor
Pred. No.:
1.
1.
19 Staniford Street
Boston, MA 02114-2589
Pred. Date:
2.
2.
Pred. Cd.:
PLEASE TYPE OR PRINT CLEARLY IN INK.
3.
3.
ESR Status:
CALL (617) 626-5075 FOR ASSISTANCE.
4.
4.
Leasing Code:
Employer Type:
Fax: (617) 727-8221
5.
5.
% CO
Name of employing unit:________________________________________Trade name:______________________________________________
List ALL business locations in Massachusetts. If more than one attach a separate sheet.
No.
Street (do not use P.O. box number)
City
State
Zip Code
Mailing address:
No.
St./P.O. box no.
City
State
Zip Code
Business phone:
Area Code
Number
Address where you keep your payroll records:
Federal identifi cation no.:
(do not use P.O. box numbers)
Owner, partners or offi cers:
Are offi cers compensated
Name (Required)
S.S.A. No. (Required)
Home address
Title
for their services?
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Yes
No
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Yes
No
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Yes
No
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Type of organization:
Individual
Partnership
Corporation
Other (specify)
If corporation:
date incorporated
state
First date of employment in Massachusetts:
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Are you a client of an employee leasing company?
Yes
No
If yes, name of employee leasing company
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Are you liable for federal unemployment tax?
Yes
No
1st date of liability
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Have you previously been subject to the Massachusetts Unemployment Insurance Law?
Yes
No
If yes, give account number
name
Do you hold an exemption from federal income taxes as a non-profi t organization described under section 501 (c)(3) of the Internal Revenue Code?
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Yes
No
If Yes, please attach a copy of your exemption with this report.
Describe nature of your company's business/industry:
Specify your principal activity. Name your principal commodity, product or service.
If your main activity in Massachusetts is to provide support services to other locations of your company, please check appropriate box:
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Headquarters
Research
Warehouse
Computer Center
Other (specify)
Form 1110-A Rev. 08-05
Commonwealth of Massachusetts
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