Form Dol-1 - Employer Status Report
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1
2GEORGIA DEPARTMENT OF LABOR
SUITE 850, SUSSEX PLACE - 148 INTERNATIONAL BOULEVARD, N. E. -
ATLANTA, GA. 30303-1751
EMPLOYER STATUS REPORT
READ INSTRUCTIONS ON REVERSE SIDE
BEFORE COMPLETION OF FORM
1. ENTER OR CORRECT BUSINESS NAME AND ADDRESS
RETURN ORIGINAL WITHIN 10 DAYS
GEORGIA DOL
ACCOUNT NUMBER
_
(If already assigned)
3. TRADE NAME
2. TYPE OF ORGANIZATION
Nonprofit org.
Individual
Corporation
Partnership
Street Address
4. PRINCIPAL BUSINESS,
Limited Liability Corp. (LLC)
FARM OR
HOUSEHOLD
Other (specify)________________________
LOCATION IN
GEORGIA
City
Zip Code
County
Telephone Number
(Do not use a
GA
P. O. Box number)
(
)
5. DATE FIRST BEGAN
6. ARE YOU LIABLE
DATE OF
FEDERAL
EMPLOYING WORKERS
FOR FEDERAL
YES
NO
_
FIRST GA.
I. D.
WITHIN STATE OF GA.
UNEMPLOYMENT TAX?
PAYROLL
NUMBER
7. HAVE YOU..........
DATE ACQUIRED
DID YOU ACQUIRE..........
OR CHANGED
All of Georgia operations?
Acquired another business?
Yes
No
PREDECESSOR'S
_
GEORGIA DOL
Substantially all of Georgia operations
Merged with another business? Yes
No
ACCOUNT NUMBER
(90% or more)
DOES THE FORMER
Formed a corporation or
OWNER CONTINUE TO
Yes
No
Part of Georgia operations (less than 90%)
partnership?
Yes
No
HAVE EMPLOYEES?
Made any other change in the
ownership of your business?
Yes
No
If yes, explain
FROM WHOM? (Organization name, including trade name)
ADDRESS
9. IF YOU HAD DOMESTIC EMPLOYMENT:
8.
IF YOU HAD PRIVATE BUSINESS EMPLOYMENT:
Did you, or do you expect to pay cash wages
Did you, or do you expect to employ at least one worker Yes*
No
Yes*
No
of $1,000 or more in any calendar quarter?
in 20 different calendar weeks during a calendar year?
* If yes, show date this first occurred:
* If yes, show date the 20th week first occurred:
Yes*
No
10. IF YOU HAD AGRICULTURAL EMPLOYMENT:
Yes*
No
Did you, or do you expect to have a
Did you, or do you expect to employ 10 or more agricultural
quarterly payroll of $1,500 or more?
workers in 20 different calendar weeks during a calendar year?
* If yes, show date this first occurred:
* If yes, show date the 20th week first occurred:
11. IF YOU ARE A NONPROFIT ORGANIZATION EXEMPT
Did you, or do you expect to have a gross cash agricultural Yes*
No
FROM INCOME TAX UNDER IRS CODE 501(c)(3):
payroll of $20,000 or more in any calendar quarter?
Yes*
No
Did you, or do you expect to employ four or more
* If yes, show date this first occurred:
workers in 20 different calendar weeks during a
calendar year?
12. HOW MANY EMPLOYEES do you have, (or anticipate
(ATTACH COPY OF 501(C)(3) EXEMPTION LETTER)
when in full operation)?
* If yes, show date the 20th week first occurred:
Name
Name
INFORMATION
INFORMATION
ABOUT
ABOUT
PERSON
OWNER,
OR FIRM
Social Security
Address
ALL
WHO
Number
_
_
PARTNERS,
MAINTAINS
FINANCIAL
OR PRINCIPAL
Residence Address
City
RECORDS
OFFICER
OF BUSINESS
(ATTACH
ADDITIONAL
City
State
Zip Code
Telephone
SHEET, OR
SHEETS, IF
(
)
NECESSARY)
State
Zip Code
CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those contained
in any attached sheets signed by me are true and correct, and that I am authorized to execute this report on
behalf of the employing unit. This report must be signed by owner, partner or principal officer.
Telephone
Signature
Title
Date
(
)
PLEASE COMPLETE INDUSTRY INFORMATION ON REVERSE SIDE.
DOL-1
(R-6/95)
TA4891
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