DWS-UI
Utah Department of Workforce Service
s
Form 1N
Unemployment Insurance
Rev. 5/01
140 East 300 South, PO Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400 FAX (801) 526-9377
NONPROFIT ORGANIZATION
STATUS REPORT & ELECTION OF PAYMENT METHOD
PLEASE READ INSTRUCTIONS THEN COMPLETE ALL ITEMS (TYPE OR PRINT LEGIBLY)
9 Corporation
9 Other (specify):
1. Type of Ownership:
2. Name of Non Profit Organization and mailing address for quarterly contribution (tax) reports
4. Federal Employer ID Number (FEIN):
5. County in Utah
6. Number of
where principal
permanent Utah
activity is located:
worksites:
3. Telephone Number: (
)
Fax Number: (
)
7. Mailing address & telephone number for wage
8. Street address & telephone number of
9. Mailing address & telephone number for
and separation requests (if different from
principal worksite in Utah (if different from
Business Headquarters (if different from item
item 2):
items 2 or 7):
2):
Telephone Number: (
)
Telephone Number: (
)
Telephone Number: (
)
Fax Number: (
)
Fax Number: (
)
Fax Number: (
)
10. List organization officers names and social security numbers:
Name
SSN
Name
SSN
11. Describe in detail your principal business product and/or service:
12. Has the Internal Revenue Service issued to your organization an exemption for Federal Income Tax under Section 501(c)(3) of the Internal Revenue
Code?
9 Yes
If Yes, please attach copy of the exemption letter with this form and give date of the exemption letter: _______________________.
9 No
If No, please explain why you have received no exemption:
13. During the current, or preceding, calendar year has your organization employed four or more individuals for some portion of a day in each of twenty
different weeks?
9 Yes
If Yes, please complete the worksheet on page 3.
9 No
If No, do you expect to employ four or more individuals in the future? 9 Yes 9 No
If Yes, Estimated date:____________________
14. If you are a new business in Utah, show date started:
15. Date of first payment of wages in Utah:
16. Did you acquire the organization, trade, or business of another operation?
9 Yes If Yes, what is the date of acquisition: ___________. Please complete questions 16a thru 16f.
9 No
If No, please skip items 16a to 16f and move to item 17.
16a. Please provide the name, address and Unemployment Insurance employer ID number or FEIN of previous organization.