Form Uct-5334 - Agricultural Employer'S Report - 2013

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AGRICULTURAL
2013
Complete 1-5 If different from address at left,
EMPLOYER'S REPORT FOR
then go to #6:
Required to determine your employer status under the Wisconsin
1. Legal Name
Unemployment Insurance Act, (CHAPTER 108, WIS. STATS.)
COMPLETE AND RETURN THIS REPORT WITHIN 10 DAYS UNLESS
INSTRUCTED OTHERWISE.
2. Trade Name (D/B/A)
UI ACCOUNT NUMBER
3. Mailing Address c/o (If required for correct delivery)
4. Street or P.O. Box
5. City
State
Zip Code
6. Federal Identification Number (9 digits)
7. Person To Contact For Additional Information:
Name/Email Address
Send to:
Department of Workforce Development
Division of Unemployment Insurance
P.O. Box 7942
Telephone Number
Madison, Wisconsin 53707-7942
Telephone: (608) 261-6700
(
)
FAX: (608) 267-1400
14. Do you continue to have paid agricultural employees
email: taxnet@dwd.wisconsin.gov
8
working in Wisconsin?
Yes
No
8
8. Check Type of Ownership:
Limited Liability Company
8
Individual
State of Registration:
8
If no, give date of last employment: _____________
Limited Liability Company Electing to be
Partnership
8
Treated as Corp for Federal Tax Purposes
Yes
No
Are you presently out of business?
You must submit a copy of your IRS Notice
Corporation
of Acceptance
State of Incorporation:
Yes
No
8
Did you sell or transfer your business?
8 8
State of Registration:
Other (Estate, Trust, Receivership)
Limited Liability Partnership
- Identify:
Limited Partnership
If you sold or transferred your operation, provide:
Date you sold or transferred your operation (mo./day/yr.)
9. Provide Name(s) and Social Security Number(s) of Individual;
Partners; or Corporate Officers (Include Middle Initial):
Name(s)
S.S. No.(s)
Legal name of new owner you sold or transferred to
Street Address or P.O. Box of new owner
10. Briefly describe type of agricultural operation:
City
State
Zip Code
11. Identify the TOWN and COUNTY in Wisconsin where your agricultural
15. Do you currently have any business activity covered
operation is located:
under the Wisconsin U.I. Law?
Yes
No
If yes, provide:
12. Date you first had agricultural employees in Wisconsin:
Business Name
UI Account Number
13. Did you acquire all or part of an already established agricultural business?
Yes
No
If yes, provide:
Date of Acquisition (mo./day/yr.):
16. Do you ever have 10 agricultural employees working
for you on the same day?
Yes
No
Legal Name of Prior Owner
UI Account Number
Do you ever pay $20,000 in cash wages for agricultural
labor in a single calendar quarter?
Yes
No
Current Address of Prior Owner
If you answered 'yes' to either question,
continue to #17.
City
State
Zip Code
If you answered 'no' to both questions,
continue to #19.
UCT-5334 (R. 11/19/2012) (U00603)

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