Dws-Ui Form1 - Status Report
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1
2DWS-UI
Utah Department of Workforce Services
Form1
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
s
s
STATUS REPORT
Please Read the Instructions then Complete All Items. Type or Print Legibly.
Individual
Corporation
Partnership
LLC
Other: _______________
1. Type of Ownership:
Corporate Election
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
5. Number of
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
Separation Requests (if different from item 2):
site in Utah (if different from item 2):
information (if different from item 2):
Telephone # (
) _______________
Telephone # (
) ____________
Telephone # (
) _______________
9. List owners or corporate officers (e.g., sole proprietor, general partners, corporate officers or LLC members)
Name
SSN
Title
Home Address
Home Phone
10. Describe in detail your principal business product and/or service of your Utah operation (see instructions):
11a. Enter DATE of first Utah wages
11b. Enter
12. If Utah wages have not yet been
$
paid to employees including corporate
Amount of first
paid, give estimated DATE when you
officers. (see instructions)
Utah wages paid.
expect to pay Utah wages:
13.
Complete this Section if your business falls into one of the categories below, otherwise select:
N/A
Business has operated only in the State of Utah or
A. Construction Employer:
Business has operated in another state prior to operating in the State of Utah. Name of prior State:___________________
Employer has paid or will pay $1,000 or more in wages in a calendar quarter for domestic service. Yr/Quarter:___________
B. Domestic Employer:
Request to file UI contribution reports and payment annually on January 31st instead of filing quarterly.
Business has paid or will pay $20,000 or more in wages in a calendar quarter.
Yr/Quarter:___________
or
C. Agriculture Employer:
Business has or will have 10 or more employees working in at least 20 different weeks during the calendar yr _________.
Business is a Professional Employer Organization (PEO):
D. Leasing Company:
Utah PEO (Professional Employer Organization) registration number: ______________________
14a. Did or will your business obtain in full or part, through an acquisition, merger or transfer, the assets, the trade or business, or workforce of another
company?
NO
YES. Please complete Sections 14 and 15
Enter the date of acquisition, merger or transfer: _________________________
14b. Check the type of change:
Reorganization
Change of entity (e.g., proprietorship to corporation)
Merger
Repossession
Sale of business to new business
Lease of business to new business
Transfer of trade or business
Purchase assets of business
Transfer of workforce (employees)
Purchase assets of business from the bankruptcy court
Other: (explain) ____________________________________________________________
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