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Employer Status Report Form

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Employment

SPACE

SECURITY

Subject Date

32 SOUTH MAIN STREET

Retroactive

CONCORD NEW HAMPSHIRE 03301-4867

Successor

PHONE (603) 224-3311

Acquisition

EMPLOYER STATUS REPORT

Not Subject

No of Employees

TO ESTABLISH ITS STATUS UNDER THE PROVISIONS OF THE NEW HAMPSHIRE UNEMPLOYMENT

COMPENSATION LAW, EACH EMPLOYING UNIT IS REQUIRED BY THE LAW TO FILE WITH THIS

DEPARTMENT AN EMPLOYER STATUS REPORT (RSA 282-A). PLEASE READ CAREFULLY THE

INSTRUCTIONS ATTACHED. USE TYPEWRITTER OR PRINT IN INK

1. Business or trade name

2. Federal Identification Number

Tel #

Fax #

3. Address of principal place of business in New Hampshire, if none, indicate other state.

Number and street ( Do not use post office box)

(Town or City)

(State)

(Zip Code)

4. If correspondence, reporting forms, etc., are to be mailed to other than the principal place of business, enter mailing address.

Number and street or P.O. Box

(Town or City)

(State)

(Zip Code)

5. Enter for each establishment or operation maintained by you in New Hampshire:

Principal Activity

Principal Products, Processes or Services

Location of Each Unit

6. Check type of Business

Sole proprietorship

Partnership

Corporation

Limited Liability Co.

Other (indicate what type)

7. If a corporation, enter full corporate name :

Date of incorporation:

State of incorporation:

Name and address of New Hampshire resident agent:

8. Is your business a nonprofit organization described in Section 501 (c) (3) and exempt under 501 (A) of the Internal Revenue Code?

If Yes, attach a copy of your letter of exemption .

Yes

9. Enter Date on which employment was first furnished in New Hampshire:

I 0. Ceased to furnish employment in New Hampshire on:

Reason :

I 1. Are or will you be subject to the Federal Unemployment Tax Act in the current year?

Yes

12. Has employment been furnished in New Hampshire in preceding years during which you were subject to the Federal Unemployment Tax Act

If Yes, list years: 19

Yes

13. If you acquired the organization, trade, business or any of the New Hampshire assets of any other employing unit or employer, complete the following :

Name & Address of Prior Owner

Date Acquired

% of Assets Acquired

Were there any business assets which were not acquired ?

Yes

List any business assets not acquired

If yes, please explain

Will the prior owner remain in business in NH ?

Yes

OVER