Form Uc-1a - Employer Status Report For Unemployment Compensation - 2014
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1
2ABC
Over 6
Lag Date
UC-1A (Rev 1/14)
Registration
EMPLOYER STATUS REPORT
IC
Under 6
___________
Number: ______________________
For UNEMPLOYMENT
666
148
COMPENSATION
________________________For Office Use Only
151
713
Status ___________________________________
Other ______________________
Rate(s)___________________________________
Quarter(s)_________________________________
Predecessor Reg. No.:
Date Rec’d
___________________________
RETURN COMPLETED FORM TO:
FORM IS TO BE TYPED OR PRINTED IN INK
EMPLOYER STATUS UNIT
PLEASE COMPLETE AND RETURN THIS FORM EVEN THOUGH YOU MAY NOT BE SUBJECT TO THE
200 FOLLY BROOK BLVD.
CONNECTICUT UNEMPLOYMENT COMPENSATION LAW. *501(C)(3) NON-PROFIT ORGANIZATIONS SHOULD
WETHERSFIELD, CT 06109-1114
REQUEST FORM UC-1NP. THE STATE OF CONNECTICUT OR ITS MUNICIPALITIES SHOULD REQUEST FORM
TEL. NO. (860) 263-6550
FAX (860) 263-6567
UC-1MUN.
. (
)
_____________
1. Federal Identification Number _______________ Tel. No
______________ Email Address _________________________
2. Business or Trade Name_____________________________________________________________________________________________________
3. Name of Owner, Partners, or
Corporate name, if other than above_____________________________________________________________________________________________
4. Mailing
address___________________________________________________________________________________________________________________
Street or P.O. Box
City
Number
State
Zip Code
5. List all Connecticut business locations, if different from above. If mailing address is P.O. Box, please give the physical location of business. Attach a
separate sheet if necessary. If only a salesman in Connecticut, please indicate salesman’s home address.
___________________________________________________________________________________________________________
6a. Describe the exact nature of the business. If construction, state the type. If manufacturing, list the principal products sold and their percent of the
total. If trade, state whether retail or wholesaler and list the type of products sold. If employer of HOUSEHOLD help, so indicate.
_________________________________________________________________________________________________________
6b. State function of the Connecticut facility (i.e., headquarters, research facilities, etc.)___________________________________________________
7a. Under what type of business organization do you operate? (Check one of the following)
Individual / Sole Proprietorship
Partnership
Corporation
Other__________________________________________________
:
LLC – Sole Proprietor
LLC - Partnership
LLC – Corporation
LIMITED LIABILITY COMPANIES
7b. Corporations or LLC's complete this item:
State in which Incorporated/Organized: __________________________ Date of Incorporation/Organization: ________________________________
MM / DD / YY
8.
List proprietor, partners, corporation officers, or members of a L.L.C. (Attach a separate sheet if necessary):
Name
SS #
Title
Home Address – including Zip Code (Not a P.O. Box)
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
9. When did you first engage employees working in Connecticut under your present type of organization? _____________________________________
MM / DD / YY
Note: Officers of a corporation are considered employees for unemployment purposes.
10. Did you acquire ALL or PART of the employees, or assets, or organization, or trade and business in Connecticut of some other employer?
.
Note: Acquisition can be facilitated by a third party such as a bank or court
Yes
No
If Yes, All
Part
If only part, describe what part was acquired:__________________________________________ Date Acquired _________________________
What part was not acquired?_______________________________________________________
MM / DD / YY
Is your business owned by the same interests as the predecessor?
Yes
No
11. If the answer to Item 10 is “Yes”, complete the following:
1. Previous Employer’s Trade Name ________________________________________________________________________________________
2. Name and address of previous proprietor, partner,
or corporation officer___________________________________________________________________________________________________
3. Was the previous employer subject to Connecticut Unemployment Compensation Law?
Yes
No
Previous registration number_____________________________________________
Yes
4. Will the previous employer remain in business in Connecticut?
No
12. Were you previously or are you now registered as an employer with the Connecticut Labor Department?
Yes
No If “Yes”, indicate registration number__________________________________________________________________________
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