Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - Division Of Revenue Page 36

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STATE OF DELAWARE
UC-1 01/2014
DEPARTMENT OF LABOR
Document 60 06 0114 01 01
DIVISION OF UNEMPLOYMENT INSURANCE
PO BOX 9953 WILMINGTON DE 19809-0953
302-761-8482
)
(DO NOT FILL IN THIS SPACE
This report is to be filled in and returned
Employer Number____________________
REPORT TO DETERMINE LIABILITY
to this office within 10 days of its receipt
Ind. Code and Area ___________________
AND IF LIABLE
whether or not you are liable for
Effective Date of Liability______________
APPLICATION FOR
assessments under Part III, Title 19,
Assessment Rate _____________________
EMPLOYER ACCOUNT NUMBER
Delaware Code
.
Status Date _________________________
FILL IN WITH TYPEWRITER OR PRINT IN INK
- ALL QUESTIONS MUST BE ANSWERED
1. Name of Employer and Trade Name, if any:
5. Have you:
‰
1. Started a new business
‰
2. Purchased a going business (Attach Explanation)
‰
1a. Federal Employer's Identification Number:
3. Just begun having employment
‰
4. Reorganized (Attach Explanation)
‰
5. Other (Attach Explanation)
2. Street Address and Telephone Number of Main Office:
6. Ownership Information
Is business publicly held? Yes
No
If yes, provide name and Federal Employer Identification
Number of controlling entity:
3. Address to which employer's report forms and mail are to be
sent. Outside representative must file a notarized power of
If no, complete ownership information below. If more
attorney.
than one owner, attach additional information. Percentage
of ownership must total 100%
Name
3a. E-Mail Address:
Social Security Number
4. Have you previously filed an application for a Delaware U.I.
Address
account number? Yes
No
% of Ownership
7. On what date did you first employ any
8. Are you liable as an employer under
9. Do you own or control any other employing
workers in Delaware?
the Unemployment Compensation
unit in Delaware?
Laws in any other state?
7a.Will gross payroll meet or exceed
No
rd
th
$1500.00 in either 3
or 4
Quarter?
Yes
No
Yes
Account #______________
Yes
No
10. State total number of workers in covered employment in Delaware and total payroll by calendar
11.
Check (9) form of organization
‰
quarter. If unknown, you may estimate these numbers
Individual
.
‰
Effective 1/1/96, wages of all corporate officers are reportable.
Partnership
‰
MARCH
JUNE
SEPT.
DEC.
Delaware Corporation
Employees
Payroll
Employees
Payroll
Employees
Payroll
Employees
Payroll
‰
Out-Of-State Corporation
‰
2010
Non-Profit
‰
Estate or Trust
2011
‰
LLC (attach # Form 8832)
or written explanation
2012
2013
11a. Date of Incorporation
______________________
2014
COMPLETE REPORT ON REVERSE SIDE AND SIGN

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