State Form 15672 - Report For Seasonal Determination - 2003
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INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
REPORT FOR SEASONAL DETERMINATION
10 N. SENATE AVE., RM SE204
State Form 15672 (R4/10-09), DWD Form 2003
INDIANAPOLIS IN 46204-2277
Local: (317) 233-6715 Toll Free: 1-800-437-9136 Fax: 317-233-2706
.
Pursuant to Indiana Code 22-4-7-3, the undersigned Employer hereby makes application to become a Seasonal Employer for all or designated portions of its
Indiana operations. This form must be updated every two years to keep your Seasonal Determination active.
Date:
1. Indiana SUTA No.:
(
)
FEIN:
-
•
Legal Name of Employing Unit
•
d/b/a
•
Business Address
PO Box
City
State
ZIP Code
-
Describe the nature of your business:
2. List below the name and location of each distinct and segregable portion of your business that you wish to be claimed as
Seasonal (attach additional sheets if you have more than seven (7) units).
NAME
LOCATION
A.
B.
C.
D.
E.
F.
G.
3. Describe the nature of the business that you consider Seasonal under Item 2, and indicate ACTUAL DATES of Seasonal
operating period (must be less than 26 weeks).
NATURE OF OPERATION
OPERATING PERIOD
A.
B.
C.
D.
E.
F.
(please complete the reverse side of this report)
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