Form 1110-A - Employer Status Report Page 2
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Have you undergone any type of organizational change?
Yes
No
You must answer "yes" if any of the following apply: You acquired All or Part of another business or organization operating in MA; you were part of
a merger with (or consolidation of) a business operating in MA; you changed your Federal Identifi cation Number; you have had a relationship with
or are a "spin-off" of a company registered with MA DUA; you changed organizational structure. This includes any changes from one business type
to another (examples include—but not limited to—changes from a sole proprietorship to corporation, LLC, LLP, etc., or from a corporation to a sole
proprietor, partnership, LLP Trust, etc).
Name of predecessor:
Predecessor DUA account number:
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Did you acquire ALL or PART of the business of the predecessor?
ALL
PART
Acquisition of one of several locations in Massachusetts is considered PART of the business.
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How acquired?
Purchase
Lease
Franchise
Other
(explain)
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Did you acquire the assets of the predecessor's business?
Yes
No
If Yes, state: date acquired:
Describe those assets acquired:
Describe those assets NOT acquired:
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Will the predecessor remain in business in Massachusetts?
Yes
No
If No, give the date of last payroll:
If Yes, what is present Massachusetts location of predecessor?
Number of Employees:
No.
Street
City
State
Zip Code
DOMESTIC EMPLOYERS:
Did you pay $1,000 or more in cash remuneration in any calendar quarter during the current or preceding calendar year for
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domestic services?
Yes
No
AGRICULTURAL EMPLOYERS:
Did you pay $20,000 or more in cash remuneration for agricultural services during any calendar quarter of the current or preceding
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calendar year?
Yes
No
Did you employ 10 or more individuals on some day in each of 20 calendar weeks, not necessarily consecutive, in either the current
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or preceding calendar year?
Yes
No
ALL OTHER EMPLOYERS:
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Did you pay wages of $1,500 or more in any calendar quarter in either the current or preceding calendar year?
Yes
No
Did you employ one or more individuals on some day in each of 13 weeks, not necessarily consecutive, in either the current or preceding
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calendar year?
Yes
No
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If an "OUT OF STATE" employer, did you have a Massachusetts payroll in excess of $200?
Yes
No
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