Form Mdes-1499a - Questionnaire To Determine The State To Which Wages Are Properly Reported

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QUESTIONNAIRE TO DETERMINE THE STATE
TO WHICH WAGES ARE PROPERLY REPORTED
Minnesota Department of Economic Security - Tax Office
Tel: (651)296-3624 Fax: (651) 297-5283 TDD/TTY: (651) 297-3944 Internet:
EMPLOYER_____________________________________
WORKER ____________________________________
- 000
-
-
ACCOUNT NUMBER_____________________________
SOCIAL SECURITY#__________________________
This test is applied separately to each quarter. The worker's
Quarter(s) or
wages may not be reportable to the same state for all quarters.
time period: ___________________
I.
Did the worker work for the employer only in one state?
Yes ______ If yes, in which state did the worker work? __________________
(All wages are properly reported to this state.)
No ______ If no, was the worker permanently transferred from a job location in one state to a job location in another
state?
Yes ______ If yes, give the names of the states and dates services were performed in each state:
State:______________________ From:_____________ To:____________
State:______________________ From:_____________ To:____________
(Wages are properly reported to both of these states.)
No ______ If no, List the names of all the states where this worker worked for this employer:
__________ __________ __________ __________ __________ __________
Was the work in any of these states non-regular (i.e., temporary, incidental or transitory)?
(Examples: A temporary or an incidental task, meeting, sale delivery, commuting, or just
traveling through a state)
No ______ If no, then proceed to question II
Yes ______ If yes, then cross out the state(s) above with non-regular employment..
Is 80% or more of the worker’ s services during the quarter performed in any one state?
No ______ If no, then proceed to question II.
Yes ______ If yes, name that state. _____________
(All the quarterly wages are reportable to this state.)
II.
Did the worker routinely report in person to, or work directly out of a store, shop or office (including an office
in the worker’ s home)?
If no, then proceed to question III below.
No _____
If yes, where is that store, shop, or office located? State ____________
Yes _____
(Wages are properly reported to this state.)
III.
Did the worker work in a state where the employer had an office from which the worker received instructions?
If no, then proceed to question IV below.
No _____
If yes, where was that office located? State ______________
Yes _____
(Wages are properly reported to this state.)
IV.
Did the worker work out of the worker’ s home and in the state of the worker’ s residence ?
If no, then proceed to question V below.
No _____
If yes, where is the worker’ s residence? State ________________
Yes _____
(Wages are properly reported to this state.)
If the answer to ALL of the above questions is “no” then the wages are properly reported to the state of the
V.
employer’ s branch office or headquarters. State:___________________
Wages are to be reported to state: _____________________for Year/Qtr(s): ______________________
SIGNATURE________________________________________ TITLE________________
________________________
Date:
Tel:#
MDES-1499A (Rev.98)

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