Form De 1ag - Registration For Agricultural Employers - 2001

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This form will be the basic record of YOUR
EMPLOYMENT DEVELOPMENT DEPARTMENT
ACCOUNT. DO NOT FILE THIS FORM UNTIL
ACCOUNT SERVICES GROUP, MIC 28
YOU HAVE PAID WAGES THAT EXCEED
P.O. BOX 826880
$100.00. Please read the INSTRUCTIONS on the
SACRAMENTO CA 94280-0001
back before completing this form. PLEASE PRINT
(916) 654-7041 / FAX 654-9211
OR TYPE. Return this form to:
REGISTRATION FORM FOR AGRICULTURAL EMPLOYERS
ACCOUNT NUMBER
QUARTER
ETCSO
FED CODE
ON-LINE PROCESS DATE
TAS CODE
DEPT. USE ONLY
A.
OWNERSHIP BEGAN OPERATING
FEDERAL I.D. NUMBER
BUSINESS NAME
MONTH:
DAY:
YEAR:
B.
Social Security No./Corp. or LLC I.D. No.
DRIVER’S LICENSE NUMBER
OWNER, CORPORATION, OR LIMITED LIABILITY COMPANY (LLC)
NAME
List all partners, *corporate officers,
TITLE
SOCIAL SECURITY NUMBER
DRIVER'S LICENSE NUMBER
LLC Members, Managers and Officers
(Partner, Officer Type, LLC
Member, LLC Manager)
*If entity is a Limited Partnership, indicate General Partner with an (*). List additional partners, LLC members, officers on a separate sheet.
C.
CITY OR TOWN
STATE
ZIP CODE
COUNTY
BUSINESS LOCATION Street and Number (see instructions)
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.
HAVE YOU EVER BEEN REGISTERED WITH
IF YES, ENTER EMPLOYER ACCOUNT NUMBER, BUSINESS NAME AND ADDRESS
THE DEPARTMENT?
ACCOUNT NUMBER
BUSINESS NAME
ADDRESS
No
Yes
E
F.
.
Will you withhold Personal Income Tax from any employee wages?
No
Yes
Indicate first quarter and year in which wages exceeded $100.00
Jan.-Mar. 20__
July-Sept. 20__
If “yes” will you be subject to Federal monthly/semi-weekly deposits?
Apr.-June 20__
Oct.-Dec. 20__
No
Yes
G.
H.
ORGANIZATION TYPE
DO YOU EMPLOY NON-AGRICULTURAL WORKERS?
No
Yes
(IN) INDIVIDUAL OWNER
(HW) HUS/WIFE CO-OWNERSHIP
If yes, please enter:
(GP) GENERAL PARTNERSHIP
(CP) CORPORATION
Account Number:
(LC) LIMITED LIABILITY COMPANY
(OT) OTHER (Specify)
Business Name:
I.
J.
List your principal crop(s) or commodities:
Number of Employees
K.
PHONE
CONTACT PERSON FOR BUSINESS
NAME
TITLE
ADDRESS
(
)
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.
(1)
Control Administrative (headquarters, etc.)
(3)
Storage (warehouse)
(5)
Does not apply
(2)
Research, development, or testing
(4)
Other (specify)
M.
Is this a(n):
New business
On-going business just purchased
(
All
Part)
Other
Change of partner(s)
Change in form – (Sole proprietor to partnership; partnership to corporation; partnership to limited
liability company; 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
(Owner, Partner, Officer, Member, Manager)
Street
City
State
ZIP Code
DE 1AG Rev. 4 (6-01) (INTERNET)
Page 1 of 3
CU

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