Form 1n - Nonprofit Organization Status Report & Election Of Payment Method - 2001

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DWS-UI
Utah Department of Workforce Service
s
Form 1N
Unemployment Insurance
Rev. 5/01
140 East 300 South, PO Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400 FAX (801) 526-9377
NONPROFIT ORGANIZATION
STATUS REPORT & ELECTION OF PAYMENT METHOD
PLEASE READ INSTRUCTIONS THEN COMPLETE ALL ITEMS (TYPE OR PRINT LEGIBLY)
1. Type of Ownership:
Corporation
Other (specify):
2. Name of Non Profit Organization and mailing address for quarterly contribution (tax) reports
4. Federal Employer ID Number (FEIN):
5. County in Utah
6. Number of
where principal
permanent Utah
activity is located:
worksites:
3. Telephone Number: (
)
Fax Number: (
)
7. Mailing address & telephone number for wage
8. Street address & telephone number of
9. Mailing address & telephone number for
and separation requests (if different from
principal worksite in Utah (if different from
Business Headquarters (if different from item
item 2):
items 2 or 7):
2):
Telephone Number: (
)
Telephone Number: (
)
Telephone Number: (
)
Fax Number: (
)
Fax Number: (
)
Fax Number: (
)
10. List organization officers names and social security numbers:
Name
SSN
Name
SSN
11. Describe in detail your principal business product and/or service:
12. Has the Internal Revenue Service issued to your organization an exemption for Federal Income Tax under Section 501(c)(3) of the Internal Revenue
Code?
Yes
If Yes, please attach copy of the exemption letter with this form and give date of the exemption letter: _______________________.
No
If No, please explain why you have received no exemption:
13. During the current, or preceding, calendar year has your organization employed four or more individuals for some portion of a day in each of twenty
different weeks?
Yes
If Yes, please complete the worksheet on page 3.
No
If No, do you expect to employ four or more individuals in the future?
Yes
No
If Yes, Estimated date:____________________
14. If you are a new business in Utah, show date started:
15. Date of first payment of wages in Utah:
16. Did you acquire the organization, trade, or business of another operation?
Yes If Yes, what is the date of acquisition: ___________. Please complete questions 16a thru 16f.
No
If No, please skip items 16a to 16f and move to item 17.
16a. Please provide the name, address and Unemployment Insurance employer ID number or FEIN of previous organization.

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