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INFORMATION FOR COMPLETING STATUS APPLICATION

Enclosed is a Report to Determine Status/Application for Employer Number. The Tennessee Employment Security

Law and Regulations requires each employing unit in Tennessee to file this report with the Department of Labor and

Workforce Development for the purpose of determining status. If you answer “Yes” to question 6(d) or any one of the

questions in items 7, 8 or 9 on the status application, you are liable for unemployment insurance coverage with this

department. Please complete and submit the enclosed form as soon as you have paid wages for services performed in

Tennessee.

The requirements for liability are:

REGULAR BUSINESS EMPLOYERS

Items 7 A and B on the status application do not pertain to farm or household employees.

During some part of a day in each of twenty calendar weeks of a calendar year, did you

Item 7A.

employ or do you expect to employ one or more persons? (The weeks need not be consecutive

and both full and part-time workers are counted.)

Have you paid or do you expect to pay wages of $1,500 or more in any calendar quarter?

Item 7B.

HOUSEHOLD EMPLOYERS

Did you have or do you expect to have a calendar quarter in which you paid household

Item 8.

employee(s) $1,000 or more in cash wages? If so, you are liable for all wages paid during

that year and the following calendar year.

AGRICULTURAL EMPLOYERS

During some part of a day in each of twenty weeks of a calendar year did you employ or do

Item 9A.

you expect to employ ten or more persons? (The weeks need not be consecutive and both full

and part-time workers are counted.)

Have you paid or do you expect to pay wages of $20,000 or more in any calendar quarter?

Item 9B.

Leave the space under Item 1 for Federal Number blank if you have not yet been assigned a FEIN (Federal Employer

Identification Number). You will receive a letter asking for this number after we establish your state account. Return the letter

with your FEIN when you receive the number from the Internal Revenue Service.

If you are completing quarterly reports and/or the Application for Transfer of Experience Rating (LB-0483), please return

them in the same envelope with this application. DO NOT write in the box titled State Account Number if you are submitting

quarterly Premium (LB-0456) and Wage (LB-0851) Reports along with this application. Your new number will be recorded

here when assigned.

Anyone who is paid for personal services by a corporation is considered to be an employee of the corporation even if that

person is an officer and/or owns stock in the corporation.

NOTE: PLEASE BE SURE TO SIGN YOUR STATUS APPLICATION at the bottom and include the appropriate information.

Also, complete both pages of your Status Application form.

Failure to complete both pages of the application or to provide sufficient information upon which to

correctly classify the industry code will result in the highest new employer rate being assigned.

LB-0441 (Revised 04-11)

RDA 1559

Form Lb-0441 - Report To Determine Status Application For Employer Number - Tennessee Department Of Labor And Workforce Development Page 3