Form C-1 - Status Report printable pdf download

ATTN: EMPLOYER SERVICES

TELEPHONE: 802-828-4344

VERMONT DEPARTMENT OF LABOR

P.O. BOX 488

FAX: (802) 828-4248

VERMONT EMPLOYER NUMBER

STATUS REPORT

C-1 (12/16)

MONTPELIER, VERMONT 05601-0488

COMPLETE BOTH SIDES OF THIS FORM, AND RETURN WITHIN 10 DAYS.

OR GO TO "EMPLOYER ONLINE SERVICES" AT

INCOMPLETE FORMS WILL

DELAY REGISTRATION.

YOU WILL BE INFORMED OF YOUR VERMONT UI LIABILITY

DEPARTMENT CONTACT

1. FEDERAL ID NUMBER

2. EMPLOYER'S LEGAL NAME

5. MAILING ADDRESS

STREET

3. TRADE OR DBA NAME (LIST ALL)

CITY

STATE

ZIP CODE

4. ATTENTION OR C/O NAME

5A. E-MAIL ADDRESS/WEB ADDRESS

5B. TELEPHONE NO.

5C. FAX NUMBER

6. TYPE OF ORGANIZATION (CHECK ONE)

SOLE-PROPRIETORSHIP OR DOMESTIC

PARTNERSHIP

CO-OWNER (Husband/Wife or Civil Union Partners)

MUST ATTACH IRS EXEMPTION

501 (c)(3) CORPORATION,

ASSOCIATION

TRUSTEE IN BANKRUPTCY

LIMITED LIABILITY COMPANY (LLC/LLP/L3C)

CORPORATION, SPECIFY STATE AND DATE OF INCORPORATION

6A. LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS:

NAME

SOCIAL SECURITY NO.

TITLE

HOME ADDRESS (NO P.O. BOXES)

MULTISTATE WORKERS

7. DO YOU HAVE EMPLOYEE(S) WHO WORKED FOR YOU IN ANOTHER STATE BEFORE WORKING IN VERMONT?

YES

7A. FIRST DATE OF EMPLOYMENT IN VERMONT:

DATE FIRST WAGES PAID IN VERMONT:

7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX ON WAGES PAID IN ANOTHER STATE IN PRIOR YEARS?

YES, LIST YEAR(S)

7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND THE TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED.

IF EMPLOYMENT OCCURRED PRIOR TO THE CALENDAR YEARS LISTED BELOW, PLEASE ATTACH ADDITIONAL SHEETS WITH THE NEEDED INFORMATION.

DO NOT ESTIMATE FUTURE WAGES.

A WORKER IS ANYONE PERFORMING SERVICES FOR YOUR BUSINESS, UNLESS THEY ARE EXEMPT UNDER UNEMPLOYMENT.

CALENDAR YEAR 2017 - ENTER NUMBER OF WORKERS IN EACH WEEK

ENTER QUARTERLY GROSS WAGES PAID

7-Jan

14-Jan 21-Jan

28-Jan

4-Feb

11-Feb

18-Feb

25-Feb

4-Mar

11-Mar

18-Mar

25-Mar

1-Apr

8-Apr

15-Apr 22-Apr

29-Apr

6-May

13-May

20-May 27-May 3-Jun

10-Jun

17-Jun

24-Jun

1-Jul

8-Jul

15-Jul

22-Jul

29-Jul

5-Aug

12-Aug

19-Aug 26-Aug

2-Sep

9-Sep

16-Sep

23-Sep 30-Sep

7-Oct

14-Oct 21-Oct

28-Oct

4-Nov

11-Nov 18-Nov

25-Nov

2-Dec

9-Dec

16-Dec 23-Dec 30-Dec

CALENDAR YEAR 2016 - ENTER NUMBER OF WORKERS IN EACH WEEK

ENTER QUARTERLY GROSS WAGES PAID

2-Jan

9-Jan

16-Jan

23-Jan

30-Jan

6-Feb

13-Feb

20-Feb

27-Feb

5-Mar

12-Mar

19-Mar 26-Mar

2-Apr

9-Apr

16-Apr

23-Apr

30-Apr

7-May

14-May 21-May 28-May

4-Jun

11-Jun

18-Jun 25-Jun

2-Jul

9-Jul

16-Jul

23-Jul

30-Jul

6-Aug

13-Aug

20-Aug 27-Aug

3-Sep

10-Sep

17-Sep 24-Sep

1-Oct

8-Oct

15-Oct

22-Oct

29-Oct

5-Nov

12-Nov

19-Nov 26-Nov

3-Dec

10-Dec

17-Dec 24-Dec 31-Dec

DEPARTMENT USE ONLY

STATUS NAICS

COUNTY TOWN

LMI NAICS

EXAMINED BY

DATE

LIABLE

YES

REPORTS DUE

NONE

LIABLE

IN UC

MAIL TICKLE DATE

ESTAB

RATES

TYPE

NEW

PREDECESSOR OR OLD NO.

LIAB CODE

RTA, SAME NO.

PARTIAL

RTA, NEW NO.

FULL, TRANSFER EXPERIENCE

CONTINUED ON PAGE 2

Form C-1 - Status Report

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