Form Fr-500 - Combined Business Tax Registration Application Page 4
ADVERTISEMENT
1
2
3
412a. Date first wages were paid to employees performing services in D.C.
(write N/A if there were no services performed in D.C.)
This space for official use only.
Month:
Day:
Year:
12b.For household employers only. Do you have an individual in your private
Account Number ______________________________
D.C. residence performing personal, rather than business, services to whom
you pay $500 or more in one calendar quarter?
Yes
No
Date _________________________________________
If yes: indicate the earliest quarter and calendar year when you paid $500 or
more : Quarter: _______ Year: _______
Signature _____________________________________
Check your preference for filing Contribution and Wage Reports:
Quarterly _____
Annually ______
13. Number of workers employed in D.C. (including officers)
14. List all places of business in D.C.
BUSINESS NAME
LOCATION ADDRESS
ZIP CODE
15. If the reason for registering is due to the purchase of a going business, merger, reorganization, or change of legal entity, provide the
following information including the percentage of assets acquired (if needed, attach additional explanation of transaction).
Nature of transfer (check appropriate box):
Purchase
Merger or consolidation
Foreclosure
Receivership
Lease
Corporate Reorganization
Bankruptcy
Assignment
Partnership reorganization (admission or withdrawal of one or more partners).
Other (specify in detail): ______________________________________________________________________________________________
Percent of assets acquired:
%
Date of transfer:
Month:
Day:
Year:
Predecessor’s Name
Predecessor’s Account Number
Address
Trade name under which transferred business was operated
16. COMPLETE THIS PART ONLY IF YOU ARE A NON-PROFIT ORGANIZATION
16a. Are you covered by the Federal Unemployment Tax Act?
16b. Are you a non-profit organization as described in §501(c)(3) of
Yes
No
the United States Internal Revenue Code which is determined to
If NO, are you exempt under §3306(c)(8) of the Federal
be exempt from income tax under §501(a) of such code?
Unemployment Tax Act?
Yes
No
Yes
No
(If yes, please attach a copy of the §501(c)(3) exemption letter.)
16c. Choose an option to finance unemployment insurance coverage (see instructions)
Contributions
Reimbursement of trust fund
CERTIFICATION. I declare under penalties as provided by law that Part VI (including any accompanying schedules and statements) has been examined
by me and to the best of my knowledge it is correct.
Signature
Title
Date
Telephone Number
THE COMPLETED PART VI MUST BE SIGNED BY THE OWNER, PARTNER OR PRINCIPAL OFFICER OF THE
CORPORATION, OR AGENT
(Power of Attorney must be attached if signed by an agent.)
Mail Part VI to: Department of Employment Services
609 H St., N.E., Room 362
Washington, D.C. 20002
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial