Form De 1p - Employers Depositing Only Personal Income Tax Withholding Registration And Update Form - 2016 Page 2

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EMPLOYERS DEPOSITING ONLY PERSONAL
INCOME TAX WITHHOLDING
REGISTRATION AND UPDATE FORM
001P11152
G. CORPORATE
CA Driver
NAME
TITLE
SSN
License
Add Chg. Del.
OFFICER(S),
Number
PARTNERS, OR
LLC MEMBER(S),
MANAGER(S),
AND/OR
OFFICER
INFORMATION
H. LEGAL NAME OF ORGANIZATION (Corporation/LLC/LLP/LP: Enter exactly as it appears on your offi cial registration documents.)
I.
DOING BUSINESS AS (DBA) (If applicable)
J.
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
K. DATE OWNERSHIP BEGAN (MM/DD/YYYY)
____/____/______
L.
STATE OR PROVINCE OF INCORPORATION/ORGANIZATION
M. CALIFORNIA SECRETARY OF STATE ENTITY NUMBER
N. PHYSICAL BUSINESS
Street Number
Street Name
Unit Number (If applicable)
LOCATION
(PO Box or Private
City
State/Province
ZIP Code
Country
Mail Box will not be
accepted.)
Business Phone Number
O. MAILING ADDRESS
Street Number
Street Name
Unit Number (If applicable)
(PO Box or Private Mail
Box is acceptable.)
City
State/Province
ZIP Code
Country
Same as above
Phone Number
P.
E-MAIL
Valid E-mail Address
Check to allow
e-mail contact.
Q. INDUSTRY ACTIVITY
Describe in detail your specifi c product/services:
Select your business industry
Services
Retail
Wholesale
Manufacturing
Other (Specify) ______________________
R. CONTACT PERSON
Name
Contact Phone Number
E-mail Address
(Complete a Power of
Attorney [POA] Declaration
Relation
Address
[DE
48], if applicable.)
S. DECLARATION
I certify under penalty of perjury that the above information is true, correct, and complete, and that
these actions are not being taken to receive a more favorable Unemployment Insurance rate. I further
certify that I have the authority to sign on behalf of the above business.
Signature
Date
Name
Title
Phone Number
PRINT
DE 1P Rev. 10 (2-16) (INTERNET)
Page 2 of 4

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