Form C-1 - Status Report printable pdf download

VERMONT DEPARTMENT OF EMPLOYMENT & TRAINING

P.O. BOX 488

VERMONT EMPLOYER NUMBER

MONTPELIER, VT 05601-0488

STATUS REPORT

C-1 WEB (12/03)

FAX (802) 828-4248

COMPLETE BOTH SIDES OF THIS FORM AND FAX OR MAIL TO THE ABOVE.

YOU WILL BE INFORMED BY MAIL OF YOUR VERMONT UNEMPLOYMENT INSURANCE LIABILITY.

1. FEDERAL IDENTIFICATION NUMBER

2. EMPLOYER'S LEGAL NAME

5. MAILING ADDRESS

STREET

3. TRADE OR DBA NAME (LIST ALL)

CITY

STATE

ZIP

4. ATTENTION OR C/O NAME

5A. E-MAIL ADDRESS/WEB ADDRESS

5B. TELEPHONE NUMBER

5C. FAX NUMBER

6. TYPE OF ORGANIZATION (CHECK ONE)

SOLE-PROPRIETORSHIP OR DOMESTIC

PARTNERSHIP

CO-OWNERSHIP (HUSBAND/WIFE OR CIVIL UNION PARTNERS)

LIMITED LIABILITY COMPANY (LLC/LLP)

ASSOCIATION

TRUSTEE IN BANKRUPTCY

501(c)(3) CORPORATION ATTACH IRS EXEMPTION

CORPORATION - SPECIFY STATE AND DATE OF INCORPORATION

6A. LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS BELOW:

NAME

SOCIAL SECURITY NO.

TITLE

HOME ADDRESS (NO PO BOXES)

7. HAVE YOU EMPLOYED ANYONE IN VERMONT IN THE CURRENT OR PAST THREE YEARS?

YES

IF YES, COMPLETE 7A-7C

INCLUDE: Full and part time workers, students, officers of a corporation and legal aliens.

IF NO, WHEN DO YOU EXPECT TO?

EXCLUDE: Sole proprietor and spouse or civil union partner and the parents and children under 18; members of an LLC and partners of a partnership.

7A. FIRST DATE OF EMPLOYMENT IN VERMONT:

DATE FIRST WAGES PAID IN VERMONT:

7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX?

YES, LIST YEARS

7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND LIST TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED. IF EMPLOYMENT OCCURRED

PRIOR TO THE CALENDAR YEARS PRIOR TO THOSE LISTED BELOW, PLEASE ATTACHED ADDITIONAL SHEETS WITH THE NEEDED INFORMATION. DO NOT ESTIMATE FUTURE WAGES.

CALENDAR YEAR 2004

ENTER QUARTERLY GROSS WAGES PAID

3-Jan

10-Jan

17-Jan

24-Jan

31-Jan

7-Feb

14-Feb

21-Feb

28-Feb

6-Mar

13-Mar

20-Mar

27-Mar

3-Apr

10-Apr

17-Apr

24-Apr

1-May

8-May

15-May

22-May

29-May

5-Jun

12-Jun

19-Jun

26-Jun

3-Jul

10-Jul

17-Jul

24-Jul

31-Jul

7-Aug

14-Aug

21-Aug

28-Aug

4-Sep

11-Sep

18-Sep

25-Sep

2-Oct

9-Oct

16-Oct

23-Oct

30-Oct

6-Nov

13-Nov

20-Nov

27-Nov

4-Dec

11-Dec

18-Dec

25-Dec

CALENDAR YEAR 2003

4-Jan

11-Jan

18-Jan

25-Jan

1-Feb

8-Feb

15-Feb

22-Feb

1-Mar

8-Mar

15-Mar

22-Mar

29-Mar

5-Apr

12-Apr

19-Apr

26-Apr

3-May

10-May

17-May

24-May

31-May

7-Jun

14-Jun

21-Jun

28-Jun

5-Jul

12-Jul

19-Jul

26-Jul

2-Aug

9-Aug

16-Aug

23-Aug

30-Aug

6-Sep

13-Sep

20-Sep

27-Sep

4-Oct

11-Oct

18-Oct

25-Oct

1-Nov

8-Nov

15-Nov

22-Nov

29-Nov

6-Dec

13-Dec

20-Dec

27-Dec

DEPARTMENT USE ONLY

STATUS NAICS

CTY

TOWN

LMI NAICS

LIABLE

YES

REPORTS DUE

NONE

EXAMINED BY

DATE

LIABILITY

IN UC

MAIL

ESTABLISHED

TICKLE DATE

QTRS:

LIAB CODE

TYPE

NEW

PREDECESSOR

RATES

RTA, SAME NO.

PARTIAL SUCCESSOR

RTA NEW NO,

FULL SUCCESSOR, TRANS.

Form C-1 - Status Report

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