Form Wv/bus-App - Application To Secretary Of State For Name Reservation Page 4

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INSTRUCTIONS FOR COMPLETION ARE FOUND ON PAGE 10 OF THIS BOOKLET

Page 3 of 4

SECTION B: COMPLETE THIS SECTION TO REGISTER FOR AN UNEMPLOYMENT COMPENSATION ACCOUNT

All new businesses are required to complete this section.

PART 1:

Name, street address, telephone number and person to contact

Reason for applying:

where payroll records are maintained:

❑

Name

New Business

Additional location(s)

Address (Street Or P.O. Box)

❑

Merger

Purchased business

City

State

Zip Code

❑

Change of entity

Reorganization

Telephone Number

❑

Other (describe)

Contact Person

3. Date first wages paid to employees performing ser-

4. Number of employees in West Virginia:

5. Estimated gross wages paid in first calendar

vices in West Virginia. Write N/A if no services per-

quarter of operations:

formed in West Virginia):

Number of employees in other States:

6. If the reason for registering is due to the purchase of a business, merger, reorganization, or change of legal entity, provide the following information including percent of

assets acquired (if needed, attach additional explanation of the transaction):

a. Percentage of assets acquired from former business:

b. Date former business was acquired by current business:

c. Unemployment compensation number of former business, if known:

d. Predecessor Signature:

7. Have you or do you expect to employ at least ONE worker in 20 different calendar weeks

8. Have you or do you expect to have a quarterly payroll of $1500?

❑

during calendar year?

Yes

If yes, in what earliest month and year

Yes

If yes, in what earliest quarter and year will the

will the 20th week occur?

Month

Year

quarter occur? Quarter

Year

9. For employers of domestic help only:

10. For agricultural operations only:

Have you or will you have as an individual or local college club, college fraternity or

Have you or will you have 10 or more workers for 20 weeks or more in any calendar year

sorority a total payroll of $1,000 or more in the State of West Virginia during any

or have you paid or will you pay $20,000 or more in wages during any calendar quarter?

❑

calendar quarter?

Yes

If yes, indicate the earliest quarter and

Yes

If yes, indicate the earliest quarter and calendar year.

calendar year. Quarter

Year

Quarter

Year

11. Are you liable for the Federal Unemployment Tax? If yes, in what year did you become liable?

In what states?

12. Certification. This report must be signed by owner if business is operated as an individual proprietorship; by all members of a partnership if business is operated as a partnership

or joint venture; or by an authorized officer of an incorporated business.

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

PART 2

COMPLETE THIS PART IF YOU ARE A NON-PROFIT ORGANIZATION OR GOVERNMENT ENTITY

1. If you are a non-profit organization with a 501 (c) (3) exemption, have you or do you expect to employ four or more workers in 20 different calendar weeks during a calendar year?

❑

Yes

If yes, in what earliest month and year will the 20th week occur?

Month

Year

❑

2. Elect options for unemployment compensation coverage.

Contributions

Reimbursement of trust fund (See instructions on page 10)

DO NOT WRITE IN THIS SECTION

Effective Date:

Federal ID Number: