Form K-Cns 011 - Status Report - Kansas Department Of Labor Page 2
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211. Identification of Officers
SOCIAL SECURITY
DATE OF
NUMBER
LAST NAME
FIRST NAME
MIDDLE INITIAL
TITLE
BIRTH
RESIDENCE ADDRESS
12. Record by Week the Number of Persons Performing Services IN KANSAS for Current and Preceding Calendar Year.
Year
January
February
March
April
May
June
Year
July
August
September
October
November
December
13. a. Did you acquire ALL or PART of an existing business?
Yes
No
b. If YES, the date acquired. MM-DD-YYYY __ __ - __ __ - __ __ __ __
All
Part
c. Has the previous owner continued in business in KANSAS?
Yes
No
d. Do you want the previous owner's experience rating factors?
Yes
No
e. Name of previous owner: _ ______________________________
f. Previous account number:____________________________
g. Previous trade name: _________________________________
h. Previous owner's current phone number:__________________
AREA CODE
TELEPHONE
I. Previous owner's current address:______________________________________________________________________________
STREET
CITY
STATE
ZIP
K.S.A. 44-710a(b)(2) allows a successor defined in K.S.A. 44-703(h)(4) and K.S.A. 44-703 (dd), the choice to acquire the experience ratings
factors of the predecessor employer. The request for transfer must be made in writing within 120 days of the acquisition. The experience rating
factors are all of the unemployment taxes paid, annual payrolls and benefit charges of the predecessor employer. These factors are used to
compute your unemployment tax rate for subsequent years. Alternately, successor employers may elect to be assigned their industry tax rate.
14. If no liability is indicated, do you want to elect to extend unemployment insurance coverage to your employees?
Yes
No
Beginning January 1 of the current year or at the commencement of employment and continuing for not less than two calendar years,
on behalf of the employing unit, I voluntarily elect to:
Become an employer described in K.S.A. 44-703 (h), the same as other employers since no mandatory coverage is indicated.
Extend coverage to all workers performing services that are excluded from coverage by the employment security law.
15. Select a Financing Option.
If you are subject to the employment security law by having four or more employees in 20 weeks as indicated in line 12, or by voluntarily
electing coverage in line 14, you have two options of financing the payment of unemployment taxes.
REIMBURSING: Reimbursing employers are
CONTRIBUTING: For up to four years, your contribution rate will be the
industry rate assigned to new employers. After this initial coverage period,
required to reimburse the fund for any benefit
you will become eligible for a computed rate based on your own experience
charges. They are assigned a tax rate of zero.
of contributions paid, annual payrolls and benefit charges. If, in line 13, you
Reimbursing employers must file quarterly wage
reports. This option is for a minimum period of
elected to acquire your successor employer's experience rating factors, you
four calendar years.
will receive the previous employer's tax rate.
16. Would you like a field representative to contact you and provide a more complete explanation of the financing options applicable to a
501 (c) (3) organization prior to establishment of your account?
Yes
No
17. I hereby certify that this organization has made its election as set forth above,
and that I am authorized to sign this form on the organization's behalf.
Return the completed Status Report to:
Signature_________________________________________________________
Liability Determinations
Title_____________________________________________________________
Kansas Department of Labor
401 S.W. Topeka Boulevard
Topeka, KS 66603-3182
Date____________________ Telephone______________________________
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