Form K-Cns 011 - Status Report - Kansas Department Of Labor
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1
2Kansas Department of Labor
FOR KDOL USE
ACCOUNT NUMBER
BASIS LIA
LIA EFFECTIVE
401 S. W. Topeka Boulevard • Topeka, KS 66603-3182
Phone - 785-296-5027 • • Fax - 785-291-3425
ESTB. DATE
TYPE OWN
NAICS
SIC
STATUS REPORT
To Determine Unemployment Insurance Liability
FOR NON-PROFIT 501 (c) (3) ORGANIZATION
CNTY
LMIS
QTR PRINT REQUEST
1.
Date You First Paid Wages IN KANSAS
L & L
LIQ
PARTIAL
ELEC TRAN
MAN TRAN
NO TRAN
________________________________________________
Month Day Year
EXAM UNIT
DEL. ACCT UNIT
2.
Federal Identification Number – FEIN
____ ____ – ____ ____ ____ ____ ____ ____ ____
3.
Is this employing unit described in section 501 (c) (3) of the internal revenue code of 1986 which is exempt from income tax under section
501 (a) of the code?
Yes
No
If you answered "Yes", please attach a copy of your exemption letter from the Internal Revenue Service which authorizes the 501 (c) (3)
exemption. If you have not received an exemption letter, please provide a complete explanation as to why you are exempt under Section
501 (c) (3) and an approximate date when you anticipate receiving your exemption from the Internal Revenue Service.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
4.
Describe the nature of business and purpose of this organization._______________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
5.
Business or Trade Name_______________________________________________________________________________________
6.
Corporate Name_____________________________________________________________________________________________
IF DIFFERENT FROM THE BUSINESS OR TRADE NAME
7.
Mailing Address ______________________________________________________________________
____________________
STREET AND/OR BOX NUMBER
TELEPHONE NUMBER
__________________________________________________________________________________________________________
CITY
STATE
ZIP CODE
8.
Business Address in KANSAS __________________________________________________________
____________________
STREET ADDRESS – DO NOT USE P.O. BOX NUMBER
TELEPHONE NUMBER
__________________________________________________________________________________________________________
CITY
STATE
ZIP CODE
9.
Address Where Accounting Records May Be Examined _______________________________________
____________________
NAME OF INDIVIDUAL WHO MAINTAINS RECORDS
TELEPHONE NUMBER
__________________________________________________________________________________________________________
STREET & NUMBER
CITY
STATE
ZIP CODE
__________________________________
__________________________________
E-MAIL
FAX
10. Type of Organization:
a.
Corporation
b.
Community Chest
c.
Fund
d.
Foundation
e.
Other (Describe)_____________________________________________________________________________________
K-CNS 011 (Rev. 11-04)
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