Form K-Cns 010 - Employer Status Report - Kansas Department Of Labor - 2017
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4KANSAS DEPARTMENT OF LABOR
Page 1 of 5
For Internal Use Only
EMPLOYER STATUS REPORT
SUBMIT ONLINE:
MAIL:
Unemployment Tax Contributions
P.O. Box 400
K-CNS 010 (Rev. 5-17)
Topeka, KS 66601-0400
FAX:
(785) 291-3425
See instructions on page 5. The information requested in this report is required to be provided by K.S.A. 44-714(f) and K.A.R.
50-2-5. It will be used only by public officials in the performance of their public duties. Section 6103(d) of the Internal Revenue
Code authorizes IRS to exchange information with us for audits and certifications.
1. What is your type of organization / ownership? (check one below)
Individual
Limited Partnership
Estate
General Partnership
Joint Venture
Receivership
Limited Liability Company (LLC)
Corporation (Inc.)
Trust
Limited Liability Partnership (LLP)
Governmental/Political Sub-Division (if checked, answer questions 2a and 2b)
Other: ________________________________________________________________________________________
2. If you are a governmental or political sub-division, select the branch of government and your finance option:
2a. Branch of government (check one)
2b. Finance option (check one)
State
Local
Indian Tribe
Contributing
Reimbursing
Rated Governmental
3. Are you a 501(c)(3) exempt organization?
YES
NO
(if YES, answer 3a and 3b)
3a. Finance option (check one)
Contributing
Reimbursing
3b. Have you received the 501(c)(3) exemption letter from the IRS?
YES
NO (if NO, explain below)
4.
Are you a Professional Employment Organization (P.E.O.)?
YES (If YES, you must submit a separate K-CNS 015 for each client.)
NO
5. Describe the major service, activity or product in Kansas that generates the most revenue for your business:
________________________________________________________________________________________________
5a. Is your business considered to be in the construction industry?
YES
NO
6. Date you first paid wages in Kansas: _________________________
7. List your Federal Employer Identification Number (FEIN): ______________________________
8. Legal business name
: ___________________________________________________________
(Inc., LLC, LP, Sole Prop, etc.)
9. Business or trade name
________________________________________________________________
(if different than #8):
(
)
(
)
10. Business phone: _______________________________________ Business fax: ________________________________
Business Email: ___________________________________________________________________________________
11. Mailing address - Street:______________________________________________________________________________
City: ______________________________________________________ State: ________ ZIP: ____________________
12. Kansas business physical address:
Storefront/Physical Location
Job/Construction Site
Employee Residence
Street: ___________________________________________________________________________________________
City: ______________________________________________________ State: ________ ZIP: ____________________
UNEMPLOYMENT TAX CONTRIBUTIONS
P.O. Box 400, Topeka, KS 66601-0400 • Phone (785) 296-5027 • Fax (785) 291-3425
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