Looking for a Tennessee Department Of Labor Forms And Templates? Download it for free!

10. (A) Name and Address of predecessor employer

_______________________________________________________

(B) Account Number of predecessor employer _____________________

(D) Did you acquire all of your predecessor’s business in Tennessee? YES

If No, what percentage did you acquire? _____

(E) Did your predecessor continue in business in Tennessee?

YES

(F) Tennessee Employment Security Law provides for the mandatory transfer of an employer’s benefit and premium experience whenever there is

any common ownership, management or control between the predecessor and successor employers.

Did any owner or manager of this company have an ownership interest in or participate in the management or control of the

business acquired?

YES

If “YES,” please explain: __________________________________________________________________________________

Per TCA 50-7-403(b)(2)(C)(ii) “Common ownership, management or control” includes any individual who has at least a 10% ownership interest

in - or who participates in the management or control of - the predecessor’s trade or business and has a relative with a 10% ownership interest in -

or who participates in the management or control of - the successor’s trade or business.

Does anyone who had a 10% or more ownership interest in the previous company - or who participated in its management or

control - have a relative with a 10% or more interest in this company or who participates in its management or control?

YES

If “YES,” please explain: __________________________________________________________________

If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483,

Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which

the acquisition occurred.

11. Enter below the amount of total payroll for each quarter in which you have had or expect to have employment.

YEAR

JAN-MAR

APR-JUNE

JUL-SEPT

OCT-DEC

YEAR

JAN-MAR

APR-JUNE

JUL-SEPT

OCT-DEC

NOTE: If your organization is exempt from Federal Income Taxes under Section 501(C) (3) of the IRS Code, attach a copy of letter of exemption.

Non-profit public, and/or governmental organizations are not exempt from state unemployment insurance, unless certain requirements are

met. If you are unsure about your present or future unemployment insurance status, please contact us for assistance at (615)741-2486.

12. FAILURE TO PROPERLY COMPLETE THIS SECTION WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.

Briefly describe the major business activity of the account to be covered, listing any products produced or sold, or service provided.

Be as descriptive as possible. _____________________________________________________________________________________________

_________________________________________________________________________________________________________________________

In what Tennessee County is your company located? ________________________________________________________

(If account covers sales reps or other personnel working from home, list county of residence. If county is unknown, list city of residence.)

For the work location covered by this application, is the main activity to: (Check one)

Supply products and services to the general public or other companies

Support other locations of your company (if you check this, please specify below)

HEADQUARTERS (e.g. : Corporate or regional management offices)

ADMINISTRATIVE, OTHER THAN HEADQUARTERS (e.g.: data processing, public relations)

RESEARCH (e.g.: R & D, product testing, laboratory)

STORAGE (e.g.: warehouse, distribution center, equipment yard)

OTHER (please describe) (e.g.: Repair shop, security office, maintenance, employee recreation facility)

Please check the box describing your company’s major business activity:

Agriculture, Forestry, Fishing and Hunting

Real Estate and Rental and Leasing

Professional, Scientific, Technical Services

Mining

Management of Companies and Enterprises

Utilities

Administrative and Support and Waste Management

Construction

and Remediation Services

Manufacturing

Educational Services

Wholesale Trade

Health Care and Social Assistance

Retail Trade

Arts, Entertainment and Recreation

Transportation and Warehousing

Accommodation and Food Services

Information

Other Services (except Public Administration)

Finance and Insurance

Public Administration

LB-0441 (Rev. 04-11)

RDA 1559

Form Lb-0441 - Report To Determine Status Application For Employer Number - Tennessee Department Of Labor And Workforce Development Page 2

Related Articles

Related forms

Related Categories