Form Uct-43 - Preliminary Report - 2000

PRELIMINARY

REPORT FOR 2000

Required

to determine

your status under the Wisconsin

Unemployment

Insurance

Act, (CHAPTER

108,

WIS.

STATS\

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10 DAYS UNLESS

INSTRUCTED

OTHERWISE.

I

UI Account Number

I

9. Check

Type

of Ownership:

E

Individual

cl

Partnership

q

Corporation

Other

(Estate,

Trust,

Receivership)-Identify:

IO. Provide

Name(s)

and Social

Security

Number(s)

of Sole

Owner;

Partners;

or Corporate

Officers:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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I

rvame\sr

S.S. No&i

I

Il.

Wisconsin

Employment

Began:

(month/day/year)

City

12. Location

of Wisconsin

Activity:

. . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Street

Address

City

State

Zip Code

:omplete

l-5

If different

from

address

at left,

hen proceed

with

number

6:

1. Legal

Name

2. Trade

Name

(D/B/A)

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)

I

I

I

I

I

I

I

7. Person

To Contact

For Additional

Information:

Name

1

Telephone

Number

I(

1

8. Do you currently

have a business

activity

covered

under

the Wisconsin

UC Law?

If so, provide

the:

Business

Name

UI Account

Number

13. Nature

of Business

in Wisconsin:

14. Did you acquire

any portion

of an

already

established

Wisconsin

business. 7

q

Yes

0

No

If yes,

complete:

Date of Acquisition:

Legal

Name

of Prior

Owner:

UI Account

Number

Trade

Name

of Prior

Owner:

Current

“Address

of Prior

Owner:

(Street

or P.O. Box)

State

Zip Code

15.

In the

table

below

show

WISCONSIN

payroll

and number

of

employees

to

date.

Include

ONLY

individuals

hired

for

work

exclusively

or

generally

in

WISCONSIN

whether

they

are

Wisconsin

or

out-of-state

residents.

Also,

include

any

employee

whose

services

have

become

localized

in Wisconsin

upon transfer

to Wisconsin

employment.

I

1998

I

1999

I

2000

OTR. 1

GROSS

PAYROLL

1

NO. OF EMPLOYEES

1

GROSS

PAYROLL

1

NO. OF EMPLOYEES

1

GROSS

PAYROLL

1

NO. OF EMPLOYEES

2nd

3rd

4%

COMPLETE

THE SECOND

PAGE

OF THIS

REPORT

UCT-43

(!I. 11/23/99) WOOO21)