Form Sfn 41216 - Report To Determine Liability - 2001
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1
2REPORT TO DETERMINE LIABILITY
Job Service Use
JSND/CENTRALIZED SERVICES
EAN
SFN 41216 (R. 6-01)(NDUC-301)
ST
RE
Check our Web Page at
CS/BUSINESS SERVICES
BY
FR
P.O. BOX 5507
RA
YR
-1
BISMARCK, NORTH DAKOTA 58506-5507
-2
Q
EVI
701-328-2814 OR TOLL FREE 1-800-472-2952
SIC
AUX
TTY: Relay ND 800-366-6888
NAICS
AUX
LOC
OWN
Web Link to: New Business Registrations in North Dakota
Business Name
3. Telephone Number
1.
Corporate or Legal Name
4. Federal Employer ID (FEIN)
2.
Internet Address (optional):
Mail Address (Number and Street, or P.O. Box, City, State, ZIP Code)
5.
Street Address (Number and Street, City, State, ZIP Code) (If different from #5)
E-mail address hiring official (optional):
6.
Indicate name of any other business operated in North Dakota by this ownership.
7.
8. Type of Ownership
Individual
Corporation
Nonprofit Corporation
Government
Indian Tribe or Wholly Owned
Entity of an Indian Tribe
Partnership
Limited Liability Company (LLC)
(Indicate type: general, LP, LLP, etc.)
(Indicate treatment for federal income tax reporting--corporation, partnership, etc.)
Cooperative
Other (Describe)
In what state was your business originally incorporated/registered?
Date:
List the owner(s) and all partners or corporate officers. Also, any corporate director or employee having a
9.
20 percent or more ownership interest. Attach separate sheet if necessary
Social
%
Name
Home Address
Title
Security
Number*
Owner
*In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North
Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility
purposes and program performance accountability.
Date you first employed workers in North Dakota:
10.
If you are a governmental entity, Indian tribe, or wholly owned entity of an Indian tribe, go to Question 17.
Did you acquire any part of the ND assets or business of another employer or change your business status/structure
11.
in any way?
If "yes" complete this section.
Yes
No
b. ND Unemp. Insur. #
a. Employer/previous name
(if known)
c. Date of acquistion/change
d. % of assets acquired/transferred
%
e. Will the previous business/account continue in business in North Dakota?
Yes
No
f. If eligible, do you wish to continue the experience rating established by the acquired/previous business?
Yes
No
(If you do and are assigned your predecessor's tax rate, your new account
will also be chargeable for any benefits payable to your predecessor's workers.
Are you liable for federal unemployment taxes (FUTA)?
12.
Yes
No
If yes, go to Question 18. You will be covered under North Dakota law as of the first day you employ workers in
this state.
Are you a nonprofit organization exempt from income taxes under Section 501(c)(3), IRS Code?
13.
Yes
No
If yes, complete this section and attach a copy of your exemption letter from the IRS
You need not complete sections 14 and 15.
As a nonprofit organization, have you employed four or more persons during 20 weeks of any calendar year?
If yes, date the 20th week was first reached.
Yes
No
Continued on back side
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