Form De 1np - Registration Form For Non-Profit Employers
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1This form will be the basic record of YOUR
EMPLOYMENT DEVELOPMENT DEPARTMENT
ACCOUNT. DO NOT FILE THIS FORM UNTIL YOU
ACCOUNT SERVICES GROUP, MIC 28
HAVE PAID WAGES THAT EXCEED $100.00. Please
P.O. BOX 826880
read the INSTRUCTIONS on the back before
SACRAMENTO
CA
94280-0001
completing this form. PLEASE PRINT OR TYPE.
(916) 654-7041 / FAX (916) 654-9211
Return this form to:
REGISTRATION FORM FOR NON-PROFIT EMPLOYERS
D
ACCOUNT NUMBER
QUARTER
ETCSO
FED CODE
ON-LINE PROCESS DATE
TAS CODE
E
P
T
U
S
E
DATE OWNERSHIP BEGAN OPERATING
A. BUSINESS NAME
FEDERAL I.D. NUMBER
MONTH:
DAY:
YEAR:
B.
ORGANIZATION OR CORPORATION NAME
CALIFORNIA CORP. I.D. NO.
TITLE
SOCIAL SECURITY NUMBER
List all officers names
DRIVER’S LICENSE NUMBER
Indicate officer title
C. BUSINESS LOCATION Street and Number (see instructions)
CITY OR TOWN
STATE
ZIP CODE
COUNTY
FAX NUMBER:
E-MAIL ADDRESS
MAILING ADDRESS (in care of P.O. Box or Street and Number)
CITY OR TOWN
STATE
ZIP CODE
PHONE NUMBER
(
)
D. HAS THE ORGANIZATION EVER BEEN
IF YES, ENTER EMPLOYER ACCOUNT NUMBER, BUSINESS NAME AND ADDRESS
BUSINESS NAME
REGISTERED WITH THE DEPARTMENT?
A
CCT NO.
ADDRESS
NO
YES
F.
E. Indicate first quarter and year in which wages exceeded $100.
Will you be subject to Federal monthly/semi-weekly
deposits?
Yes
No
Jan.-Mar. 20 __
Apr.-June 20__
Oct.-Dec. 20 __
July-Sept. 20 __
Number of Employees
H.
Would you like information on the following Unemploy-
G. ORGANIZATION TYPE
ment Insurance alternative financing methods?
(CP) CORPORATION
(AS) ASSOCIATION
No
Cost of Benefits
(OT) OTHER (Specify)
J. Briefly describe your non-profit activity.
I. EMPLOYER TYPE
(03) Non Profit 501 C3
(10) Church or
religious orders
(02) Non Profit
(04) Non Profit School
(20) Red Cross
K. CONTACT PERSON FOR BUSINES
NAME
TITLE
ADDRESS
PHONE
(
)
L. SUPPORTIVE SERVICES
If you are part of a larger organization and you are primarily engaged in providing supportive services to other establishments of the larger
organization, check one of these boxes.
Control Administrative (headquarters, etc.)
(3)
Storage (warehouse)
Does not apply
(1)
(5)
(4)
(2)
Other (specify)
Research, development, or testing
M. Is this a(n):
(
All
Part)
New business
On-going business just purchased
Other
Change in form
(incorporation, merger, etc.)
IF THE BUSINESS WAS PREVIOUSLY OWNED, PROVIDE THE FOLLOWING INFORMATION:
Previous Owner
Business Name
Purchase Price
Date of Transfer
EDD Account Number
N. DECLARATION
These Statements are hereby declared to be correct to the best knowledge and belief of the undersigned.
Signature
Date
Residence Phone (
)
Title
Residence Address
(Officer, Administrator, etc.)
Street
City
State
ZIP Code
DE 1NP Rev. 3 (6-01) (INTERNET)
Page 1 of 3
CU
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