Fillable Employer Status Report Form (Page 2 of 2) in pdf

Employer Status Report Form Page 2

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REGULAR BUSINESS EMPLOYMENT SECTION

14. Enter the gross payroll of your business for the current and two prior calendar years :

(New Hampshire payroll only)

Calendar Year 19

1st. Qtr.

2nd. Qtr.

3rd. Qtr.

4th. Qtr.

Calendar Year 19

1st. Qtr.

2nd. Qtr.

3rd. Qtr.

1st. Qtr.

2nd. Qtr.

3rd. Qtr.

4th. Qtr.

Calendar Year 19

15. Do you expect to have a gross payroll of at least $1,500 in the current quarter?

Yes

16. Enter by week the number of workers to whom you furnished employment in New Hampshire. Show current calendar year employment first, followed by

employment in all preceding calendar years. Note: A week is seven consecutive calendar days beginning at 12:01 a.m. Sunday and ending at 12.00 midnight

on the next succeeding Saturday. (Emp. 101.01)

CALENDAR YEAR 19

CALENDAR YEAR 9

CALENDAR YEAR 19

3rd

5th

2nd

4th

1st

2nd

3rd

4th

5th

lst

1st

2nd

4th

3rd

5th

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

17. In addition to the employment shown under item 16, did you engage any ''self employed individuals, '' ''sub-contractors,'' '' consultants,'' etc.?

If answer is Yes, furnish name, trade and address ( If necessary, use block 21 and / or a separate sheet.)

Yes

DOMESTIC -HOUSEHOLD EMPLOYMENT SECTION

18. 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

19. If this report is prepared by other than a sole proprietor, this item must be completed.

I (we) declare under the pains and penalties of perjury that I (we ) prepared this report for the employing unit named herein and that this report, including any

accompanying schedules and statements, is to the best of my (our) knowledge and belief, a true, correct, and complete report based

on all the information relating to the matters required to be reported in this report of which I (we) have any knowledge

(Name)

(Firm Name)

(Date)

(Address)

(Telephone #)

(Signature)

20. THIS REPORT MUST BE SIGNED BY OWNER, ALL PARTNERS, AUTHORIZED CORPORATION OFFICERS.

It is hereby certified that the information in this report, including any attached sheet, is true and correct to the best of my (out) knowledge and belief and is signed

under the pains and penalties of perjury.

Date Signed:

SOCIAL SECURITY NO.

RESIDENT ADDRESS

TITLE

SIGNATURE

NAME (Type or Print)

21. Remarks