Dws-Ui Form1n - Nonprofit Organization Status Report & Election Of Payment Method - Utah Department Of Workforce Services
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1
2
3DWS-UI
Utah Department of Workforce Services
Form1N
Unemployment Insurance
Rev.
01/16
140 East 300 South P.O. Box 45288 Salt Lake City, UT 84145-0288
(801) 526-9235
1-800-222-2857
Fax: (801) 526-9377
NONPROFIT ORGANIZATION
STATUS REPORT & ELECTION OF PAYMENT METHOD
Please Read the Instructions then Complete All Items. Type or Print Legibly.
Corporation
Other: _______________________________
1. Type of Ownership:
2a. Telephone:
2. Business name, DBA and mailing address for UI quarterly reports:
3a. Federal Employer ID Number
(FEIN):
(
)
2b. Fax:
3b. Utah Unemployment
Registration Number:
(
)
2c. E-mail:
4. County in Utah
Number of
5.
where principal
Utah
activity is located:
permanent
work sites:
6. Mailing address & phone for Wage and
7. Street address & phone of principal work
8. Mailing address & phone for New-Hire information
Separation Requests (if different from item 2):
site in Utah (if different from item 2):
(if different from item 2):
Telephone # (
) _______________
Telephone # (
) ____________
Telephone # (
) _______________
9. List organization officers names and social security numbers:
Name
SSN
Name
SSN
Describe in detail your principal business product and/or service of your Utah operation (see instructions):
10.
Has the Internal Revenue Service (IRS) issued to your organization an exemption for Federal Income Tax under Section 501(c)(3) of the Internal
11.
Revenue Code?
YES. Please attach a copy of the exemption letter with this form and give date of the exemption letter:___________________
NO.
Please explain why you have received no exemption:
During the current, or preceding, calendar year has your organization employed four or more individuals for some portion of a day in each of
12.
twenty different weeks?
YES. Please complete the worksheet on page 3.
NO.
YES: Estimated Date: ____________
NO. Do you expect to employ four or more individuals in the future?
13.
If you are a new business in Utah, show date started:
14. Date of first payment of wages in Utah:
Did you acquire the organization, trade, or business of another operation?
15.
YES. What is the date of acquisition: _________________. Please complete questions 16 through 17d.
NO.
Please skip items 16 to 17d and move to item 18.
Please provide the Unemployment Insurance Employer ID number or FEIN of previous organization:
16.
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