Form Sfn 41216 - Report To Determine Liability - 2001 Page 2
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2When answering Questions 14 and 15, include as employees all part-time workers and non-exempt (see Employer's Guide) corporate officers
and limited liability company managers. Do not include spouse, children under 18 who live at home, or parents of an individual owner--this does
not apply to corporations or limited liability companies. This exclusion applies to partnerships only if the worker has an exempting relationship
with each partner.
14. Enter the amount of wages you have paid in North Dakota (do not estimate or include wages earned but not paid):
Jan. 1 to March 31
April 1 to June 30
July 1 to Sept. 30
Oct. 1 to Dec. 31
$
$
$
$
Current
Year
Preceding
$
$
$
$
Year
$
$
$
$
Prior
Year
15. During 20 weeks of any calendar year, have you employed:
Yes
No
a. One or more persons in general employment?
If yes, give date on which the 20th week was first reached:
b. Ten or more persons in agricultural employment?
Yes
No
If yes, give date on which the 20th week was first reached:
16. If it is determined that you are not now liable for coverage, do you want to become covered voluntarily?
Yes
No
17. Complete this section only if you are a governmental entity, Indian tribe or wholly owned entity of an Indian tribe,
or a 501(c)(3) tax exempt organization and answered yes to either Question 13 or 16.
Select one of the following benefit financing options:
Reimbursement of benefit payments attributable to employment with your organization.
Payment of taxes on your quarterly taxable payroll at the rate applicable for new employers.
Advanced reimbursements at a percent of your quarterly total payroll to be redetermined annually.
18. Have any individuals you do not consider employees performed services for you in North Dakota?
Yes
No
If yes, give reasons for excluding them and indicate number of persons involved.
19. Give a brief description of your business activity in North Dakota.
Enter on separate lines the principal product or activities of your firm. Following each item, list the percentage of sales value or receipts
received from the product or activity; i.e., retail men's clothing, electrical construction-residential, or long haul trucking-refrigerated van.
%
%
%
%
20. Business Locations: In the spaces below, enter the name of the city in North Dakota in which your employees are working
and indicate if the location is permanent or temporary. If you do not maintain an office in North Dakota, enter the name of the
city in which your employees maintain their residence.
Perm.
Temp.
Location:
Perm.
Temp.
Location:
Remarks:
21. NOTICE OF OPPORTUNITY FOR HEARING. This report will be used to determine whether you are an "employer," as
defined by NDCC 52-01-01(15). You are entitled to a hearing prior to the determination. If you wish to have a hearing,
check this box:
Yes, I want a hearing. I believe I am not an employer under NDCC 52-01-01(15).
22.
Contact Person
Title
Telephone Number
Fax Number
Signature of Authorized Representative
Title
Telephone Number
Date
SM
Job Service North Dakota is a Proud Member of America's Workforce Program
Job Service is an equal opportunity
employer/program provider. Auxiliary aids and services are available upon request.
Please print, sign, and mail to Job Service North Dakota
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Parent category: Business