Ui Form 1 - Application For An Unemployment Insurance Tax Account Number (Page 2 of 2) in pdf

16. Indicate nature

Purchase of existing business

Reorganization of existing business

Lease

Date of Acquisition

of transaction

Incorporation of existing business

Merger with existing business

Other __________

17. Previous Owner’s Legal Business or Individual Name

DBA or Trade Name, if different from Legal Name

Contact Name

18. Previous Owner’s Address (Street, City, State, Zip Code)

Phone Number

19. Previous Owner’s Unemployment Insurance Tax Account Number

Previous Owner’s Federal Identification Number

20. Did you acquire ALL or PART of the business? (Acquisition of one of several locations in Nebraska is considered PART of the business)

If you reorganized PART of the Nebraska business named in number 17, provide explanation:

ALL

PART

Yes

21. Are you serving the same customers and/or offering the same service or product as the previous owner?

Yes

22. Are you hiring the previous owner’s Nebraska workers?

23. For a transfer of experience account, check one:

Application is hereby made for a transfer of the experience account.

Do not desire a transfer of the experience account.

Undecided. (120 days from the legal date of acquisition to make a decision.)

24. Will the previous owner remain in business in Nebraska?

Yes

If no, date of last payroll.

If yes, what is the present location of previous owner? Include address (street, city, state, zip code)

If yes, how many workers

and phone number, if available.

will remain with the

previous owner?

Complete the section(s) below that apply to your business in Nebraska.

25. Since the date of first payroll in Nebraska, has your business had a total payroll of $1,500

Specify Year / Quarter

Yes

(including officers) or more in any calendar quarter, or do you anticipate in future quarters?

26. Since the date of first payroll in Nebraska, has your business had one or more workers on

Last Date

Yes

any part of a day, in twenty (20) different weeks, or do you anticipate in future quarters?

of 20th week

27. DOMESTIC (household nature) - Since the date of first payroll in Nebraska, have you paid

Specify Year / Quarter

Yes

$1,000 or more in cash wages in a calendar quarter, or do you anticipate in future quarters?

28. AGRICULTURE - Since the date of first payroll in Nebraska, did you employ ten (10)

Last Date

workers (including officers) on some part of a day in twenty (20) different weeks during

of 20th week

Yes

a calendar year?

Specify Year / Quarter

OR did you have a gross payroll in the amount of $20,000 (including officers) in a

Yes

calendar quarter, or do you anticipate in future quarters?

29. NON-PROFIT 501 (c)(3) - Since the date of first payroll in Nebraska, did you employ four (4)

Last Date

or more individuals on any part of a day, in each of twenty (20) different weeks, or do you

of 20th week

anticipate in future quarters?

Yes

30. If you are liable and your establishment is a non-profit organization exempt under Section 501 (c)(3) of the

Internal Revenue Code, or governmental, choose one:

Contributory employer: As a contributory employer, quarterly

Reimbursable employer: As a reimbursable employer, you are required

expenses are limited to the taxable wages multiplied by the

to file quarterly tax and wage reports. Expenses are incurred only

employer’s tax rate. There may be unemployment insurance

when a former worker is paid benefits. The expenses may be 26

combined tax due each quarter.

times the worker’s weekly benefit amount.

UI Benefits Contact for Worker/Employee Separations:

Name (please print)

Title

Email Address

Phone Number

I certify that the information provided in this report is true and correct to the best of my knowledge and belief.

Read

Preparer’s Name (please print)

Title

Email Address

Phone Number

Sign

Signature

Date

Here

Form UIF01B Rev. 10-19-2016

Ui Form 1 - Application For An Unemployment Insurance Tax Account Number Page 2

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