Form Lb-0441 - Report To Determine Status Application For Employer Number (2004) printable pdf download

RETURN TO:

EMPLOYER SERVICES

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT

REPORT TO DETERMINE STATUS

500 JAMES ROBERTSON PARKWAY, 8TH FLOOR

APPLICATION FOR EMPLOYER NUMBER

NASHVILLE TN 37245-3555

(615) 741-2486

FAX (615) 741-7214

OFFICIAL USE ONLY

1. Enter Federal Number, Business Name and Address

Tennessee ID#

M. No.

SIC

County

Area

Federal Number

___ ___ - ___ ___ ___ ___ ___ ___ ___

Employer Name _______________________________________

Liab. Org.

Date Liable

First Employment

Rate

_______________________________________

Trade Name

_______________________________________

Ind GI

Comp Year

Status Rec Date

ROC

MS IC

_______________________________________

Mailing Address _______________________________________

Previous No.

S I C 6

M SIC -6

AUX-SIC

_______________________________________

VERIFIED

PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:

COMPANY PHONE:

( _____ ) ___________________

__________________________________________________________

FAX: ( _____ ) __________________

NOTE: If your organization is exempt from Federal Income Taxes under Section 501(C) (3) of the IRS Code, attach a copy of letter of exemption.

2. Is your organization a Staff Leasing Company?

YES

If Yes, Tennessee license number __________

Is your organization a client of a Staff Leasing Company?

YES

Name of Owner, Partners, Corporate Officers

Social Security Number

Residential Address

CHECK (X) FORM OF ORGANIZATION

Limited Liability Company Members and Managers

and Phone

(If Board Managed), General Partners

(Attach separate sheet if necessary)

INDIVIDUAL

PARTNERSHIP

CORPORATION

LIMITED LIABILITY COMPANY

LIMITED PARTNERSHIP

OTHER

NOTE: If a Limited Liabilty Company, are you treated by IRS as a(n)

Individual Proprietorship

Partnership or as a

Corporation

5. Name of person responsible for payroll records _____________________________________

Phone Number _______________________

6. A. Number of workers in Tennessee ___________________________

D. Are you presently reporting for U.I. purposes in another state?

B. Date you first employed a worker in Tennessee ________________

Yes

If Yes, which state? ______________________

C. Date you first paid a worker in Tennessee ____________________

E. If a corporation, give Date and State of Incorporation

Date _______________

State _________________________

7. REGULAR BUSINESS EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID)

A. Have you employed or do you expect to employ at least one worker in twenty different calendar weeks during a calendar year? Yes

If Yes, give earliest month and year the twentieth week occurred (will occur). MONTH ______________________

YEAR _______________

B. Have you had or do you expect to have a quarterly payroll of $1,500 or more?

Yes

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________

YEAR ____________________

(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID)

8. HOUSEHOLD EMPLOYMENT

A. Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? Yes

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________

YEAR _______________

(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID)

9. AGRICULTURAL EMPLOYMENT

A. Have you employed or do you expect to employ at least ten or more workers in some part of a day in twenty different weeks during a calendar year?

Yes

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________

YEAR ______________

B. Have you had or do you expect to have a quarterly payroll of $20,000 or more?

Yes

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________

YEAR _______________

If you answered Yes in any one of the questions 6D, 7, 8, 9, or 10F, you are liable for unemployment insurance premiums based on the first $7,000 paid

each employee per year.

Have you previously had an account with this department?

Yes

Account Number ____________________________

Signature ____________________________________

Title _________________________

Date ________________________

Must be owner, partner, authorized limited liability company member or manager, or officer of the corporation.

PLEASE COMPLETE PAGE 2. FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.

LB-0441 (R 9/04)

(INTERNET)

PAGE 1 of 4

RDA N/A

Form Lb-0441 - Report To Determine Status Application For Employer Number (2004)

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