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Form Deed-13 - Report To Determine Liability For Unemployment Tax - Sole Proprietor - Partnership - Llc - 2001 Page 2

REPORT TO DETERMINE LIABILITY FOR UNEMPLOYMENT TAX (continued)

� � � � � � � - � � �

Write in your Minnesota Unemployment Tax Account Number:

12. INDEPENDENT CONTRACTOR OR EMPLOYEE?

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This department renders opinions and issues formal determinations regarding classification of workers.

SEND

If you have or contemplate hiring independent contractors, check the box to receive information on the

INFORMATION

factors considered in making these determinations.

13. OWNERSHIP:

Please print or type. This report must be signed by the sole proprietor, all partners, or all members. Attach additional sheets if

necessary.

I CERTIFY THAT INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.

Full Legal Name

Title

SSN

% of Ownership

Home Address

City

State

Zip Code

Signature

Phone #

Date

Full Legal Name

Title

SSN

% of Ownership

Home Address

City

State

Zip Code

Signature

Phone #

Date

Full Legal Name

Title

SSN

% of Ownership

Home Address

City

State

Zip Code

Signature

Phone #

Date

Phone #

Date

14. Form prepared by:

The Purpose of the MDES-13

Information you provide on this form will be used for the purpose of determining your liability to pay into the unemployment fund under

the Minnesota Economic Security Law and other purposes authorized by law. This information is required under Minnesota Statutes

268.043 and 268.186. Information you supply may make you liable for (1) a tax on your payroll if you are a private employer; or (2) the

reimbursement of unemployment benefits paid to your ex-employees if you are a public or nonprofit employer. Not supplying this

information could result in the assessment of taxes, interest and penalties as set forth under Minnesota Statute 268.057. Information

you furnish will be released to the Internal Revenue Service to certify the amount of employment taxes you paid this State for which you

are requesting a credit against the tax imposed by Section 3301 of the Federal Unemployment Tax Act and for such purpose and to

such entities as set forth in Minnesota Statute 268.19.

DEED-13 SOLE PROPRIETOR - PARTNERSHIP - LLC

(rev. 01-01)

Form Deed-13 - Report To Determine Liability For Unemployment Tax - Sole Proprietor - Partnership - Llc - 2001 Page 2

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