Form Uc-1a - Employer Status Report For Unemployment Compensation - 2014 Page 2
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1
2You are liable for the CT and Federal Unemployment Tax if (a) during any calendar quarter of the current or preceding year you paid
wages totaling $1,500 or more, or (b) you had, during the current or preceding calendar year, one or more employees at any time in
each of 20 calendar weeks.
13.
Were you required to file the EMPLOYER’S FEDERAL UNEMPLOYMENT TAX RETURN Treasury Form 940 for any part of the
preceding three completed calendar years? YES
NO
If “yes”, indicate the years: ________ _______ ________
14.
As of the date of this application, have you met the liability requirements for this current calendar year? YES
NO
If NO, please complete 15 and 16:
15.
If you have engaged employees and anticipate meeting the liability requirements in this calendar year you will be
subject as of the first date you engaged employees. However, a Connecticut registration number can not be issued
until you actually meet the liability requirements, unless you voluntarily accept coverage. Do you wish to accept
coverage at this time? YES
NO
16.
If you have engaged employees and do NOT meet the liability requirements in this calendar year, but anticipate meeting
the liability requirements next year, you will be subject commencing January 1
.
However, a Connecticut registration
number can not be issued until you actually meet the liability requirements, unless you voluntarily accept coverage
commencing January 1. Do you wish to accept coverage? YES
NO
17.
List below the gross wages paid to individuals in your employ in Connecticut. Include FULL and PART-TIME employees and
OFFICERS, if a corporation. See UC-1A Instructions for the definition of gross wages.
st
nd
rd
th
1
Quarter
2
Quarter
3
Quarter
4
Quarter
(Jan. 1 – Mar 31)
(Apr. 1 – June 30)
(July 1 – Sept. 30)
(Oct. 1 – Dec. 31)
Current Year
____________
$______________
$______________
$______________
$_____________
Prior Year 1
____________
$______________
$______________
$______________
$_____________
Prior Year 2
____________
$______________
$______________
$______________
$_____________
Note: For Domestic (Household)
and Agricultural
please check box and list only cash wages above
18.
AGRICULTURAL EMPLOYERS – Did you employ 10 or more agricultural workers (excluding aliens admitted to the United
States pursuant to Sections 214 (c) and 101 (a)(15)(H) of the Immigration and Nationality Act) for some portion of a day during
any 20 calendar weeks, not necessarily consecutive, in either the preceding or current calendar year?
th
YES
NO
If “Yes”, list the week-ending date when the 20
week of employment was (or will be) met _______________
Did or will you pay cash wages of $20,000, or more in any calendar quarter of the preceding or current calendar year?
YES
NO
19.
DOMESTIC EMPLOYERS: Did or will you pay cash wages of $1,000, or more in any calendar quarter in either the preceding or
current year? YES
NO
20.
Do you have individuals performing services that you believe to be excluded from coverage or whom you believe to be
independent contractors?
YES
NO
If “Yes” explain below. (Attach separate sheet if necessary).
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
21.
Bank Name: ___________________________________________________________________________________________
Address and Account Number:_____________________________________________________________________________
22.
Name of accountant and/or payroll service, if any: _____________________________________________________________
Address and Telephone Number: __________________________________________________________________________
th
Please enter the total number of employees paid wages in Connecticut during the pay period which includes the 12
day of
23.
nd
rd
each month in the first quarter you reported employment? 1st Mo. _________ 2
Mo. __________ 3
Mo. ___________
THIS FORM MUST BE SIGNED BY THE OWNER, A PARTNER, CORPORATE OFFICER, OR AN AUTHORIZED EMPLOYEE.
ALL OTHERS MUST PROVIDE DOCUMENTATION OF AUTHORIZATION (I.E., POWER OF ATTORNEY).
I certify that the information in this report is true and correct.
Prepared By________________________________________
By_____________________________________________
(Signature)
(Signature)
Print Name _____________________________________
Print Name __________________________________________
Title ____________________________________________
Address ____________________________________________
Date ___________________________________________
Title ________________
Tel. Number __________________
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