Certified Professional Employer Organization Customer Reporting Agreement (Page 2 of 3) in pdf

Certified Professional Employer Organization Customer Reporting Agreement Page 2

Part 4:

Customer Relationship Information

Is the CPEO's relationship with the customer reported in Part 2 subject to a contract

described under section 7705(e)(2) (also called a CPEO contract)?

Yes

No*

*If “No,” skip lines 11-13.

Is the customer reported in Part 2 a provider of employment-related services (for example,

Yes

a professional employer organization)?

Is the customer reported in Part 2 a related party of the CPEO?

Yes

Does the CPEO apply the exemptions, exclusions, definitions, and other rules which are

based on type of employer under sections 3511(a)(2) and 3511(c)(2) to the customer

reported in Part 2? .

Yes

Part 5:

Customer Signature

I declare that I have examined this form, and to the best of my knowledge and belief, Parts 1, 2, and 4 are true, correct, and complete. I certify that

I have the authority to execute this form for the customer reported in Part 2.

✗

Sign your

Print your

name here

Print your

title here

Date

Email address

Best daytime phone

Part 6:

CPEO Signature

Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, it is true, correct, and complete. I

certify that I have the authority to execute this form for the CPEO reported in Part 3.

✗

Sign your

Print your

name here

Print your

title here

Date

Email address

Best daytime phone

8973

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