Form Uia 1155 - Application For Designation As Seasonal Employer

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UIA 1155
(Rev. 05-15)
S
M
Authorized by MCL 421.1, et seq.
tate of
ichigan
Talent Investment Agency
Completion of this form is voluntary.
Unemployment Insurance Agency
Rick Snyder
Sharon Moffett-Massey
Tax Office – Suite 12-600
Governor
3024 W. Grand Blvd. • Detroit, MI 48202
Director
313-456-2180 •
Application for Designation as Seasonal Employer
Reset Form
COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR BUSINESS:
1.
Name of Employer:___________________________________________________
UIA Employer Account No.:_______________________
DBA:______________________________________________________________
FEIN Number:__________________________________
Mailing
Date You Began
Address:___________________________________________________________
Business in Michigan:____________________________
City, State, Zip:______________________________________________________
SIC Code:_____________________________________
(For UIA Use Only)
COMPLETE THE FOLLOWING TABLE:
2.
If you have operated this business in Michigan for at least 1 season, give the beginning and ending dates of your seasonal work periods for each
season you have operated, up to 5 seasons; also give the total number of workers you employed in Michigan during each of those seasonal
work periods, and the total number of workers you employed in Michigan during the week the season ended and the prior 51 weeks. Count all
workers regardless of how few days or hours they may have worked for you during the season. You may designate a normal seasonal work
period, in the space provided below the table, or one will be assigned by the UIA based either on the earliest beginning and latest ending dates
you have provided or, if that is more than 26 weeks, then based on your most recent seasonal work period.
If you have already been designated as a seasonal employer
and wish to change your seasonal work period, please check here. .......................................................................................................
If you have not operated this business before in Michigan, disregard the table; instead, indicate your expected normal seasonal work period,
up to 26 weeks. F
rom _________________________ through _________________________.
Total Workers in 52
Past 5 Completed
Date Season Began
Date Season Ended
Number of Seasonal
Weeks Including the
Seasons
(Month, Day, Year)
(Month, Day, Year)
Workers
Week Each Season
Ended
Last Season
2 Seasons Ago
3 Seasons Ago
4 Seasons Ago
5 Seasons Ago
Within the period from the earliest beginning date of any season to the latest ending date of any season,
shown above, what period (up to 26 weeks) do you wish to designate as your normal seasonal work period?
From ______________________ through _____________________.
3. CERTIFICATION:
I certify that the information I have given on this application form is accurate and complete to the best of
my knowledge and belief. I understand that the designation of this employer as seasonal can be revoked if
information on this form is inaccurate, and that criminal penalties under Section 54 of the Michigan Employment
Security Act can be imposed if false statements or misrepresentations are made on this form.
___________________________________________________________________________________
_________________________
Signature of person completing this application
Date of Signature
___________________________________________________________________________________
_________________________
Printed or typed name of person completing this application
Telephone No.
THE LAW REQUIRES THE EMPLOYER TO POST A COPY OF THIS COMPLETED APPLICATION
IN A PLACE WHERE ALL WORKERS CAN SEE IT, AND TO SUBMIT THE ORIGINAL TO THE UIA,
AT THE ADDRESS ABOVE, NOT LESS THAN 20 DAYS BEFORE THE SEASON WILL BEGIN.
TIA is an equal opportunity Employer/Program.

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