Form Lb-0441 - Report To Determine Status - Application For Employer Number - 2016
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1
2RETURN TO: TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER ACCOUNTS/EMPLOYER SERVICES
REPORT TO DETERMINE STATUS
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE TN 37243-1002
APPLICATION FOR EMPLOYER NUMBER
(615) 741-2486
FAX (615) 741-7214
OFFICIAL USE ONLY
1. Enter Federal Number, Business Name and Address
Tennessee ID Number
M. No.
County
Alt Zip
Federal Number
___ ___ - ___ ___ ___ ___ ___ ___ ___
Employer Name ________________________________________
Liab. Org.
First Employment
Date Liable
________________________________________
Trade Name
________________________________________
Comp Year
NAICS
M-NAICS
Verified
________________________________________
Mailing Address ________________________________________
Previous No.
Rate
________________________________________
____________________________________
PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:
____________________________________
______________________________________________________
Phone:____________________
Fax:___________________
______________________________________________________
Business Website:_______________________________________
Email Address: ______________________________________
2. Have you previously had an account with this department? YES
NO
If YES, Account Number _______________________
3. Is your organization a
If YES, Tennessee license number ________________
Professional Employer Organization
(PEO)?
YES
NO
Is your organization a client of a
Professional Employer Organization
(PEO)? YES
NO
If YES, STOP.
Please complete LB-0910, Application for Client Number.
STOP
STOP
NOTE:If corporation is a nonprofit, exempt from Federal Income Taxes under Section 501(C)(3) of the IRS Code, STOP.
Please complete LB-0444, Report to Determine Status, Nonprofit Organization.
5.
4. CHECK (X) FORM OF ORGANIZATION
Social Security Number
Name of Owner, Partners, Corporate Officers, Limited Liability Company
Members and Managers (If Board Managed), General Partners
(Attach separate sheet if necessary.)
INDIVIDUAL
_________________________________________________________________________
PARTNERSHIP
_________________________________________________________________________
CORPORATION
_________________________________________________________________________
LIMITED LIABILITY COMPANY
_________________________________________________________________________
LIMITED PARTNERSHIP
_________________________________________________________________________
OTHER
_________________________________________________________________________
NOTE: If a Limited Liability Company, are you treated by IRS as a(n)
Individual Proprietorship
Partnership or as a
Corporation?
6. Name of person responsible for payroll records _____________________________________
Phone Number _______________________
7. A. Number of workers you have employed (will employ) in TN _________________ D. Are you presently reporting for U.I. purposes in another state?
YES
NO
If YES, which state? __________________
B. Date you first employed (will employ) a worker in TN __________________
E. If a corporation or LLC, provide formation information.
C.Date you first paid (will pay) a worker in Tennessee __________________
Date ______________ State _____ Control No. ______________
8. REGULAR BUSINESS EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you expect to employ at least one worker in twenty different calendar weeks during a calendar year? YES
NO
If YES, give earliest month and year the twentieth week occurred (will occur). MONTH ______________________
YEAR ______________
B. Have you had or do you expect to have a quarterly payroll of $1,500 or more? YES
NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________
YEAR ______________
9. HOUSEHOLD EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? YES
NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________
YEAR _____________
10. AGRICULTURAL EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you expect to employ at least ten or more workers in some part of a day in twenty different weeks during a calendar year?
YES
NO
If YES, give earliest month and year this occurred (will occur). MONTH ______________________
YEAR ___________
B. Have you had or do you expect to have a quarterly payroll of $20,000 or more? YES
NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________
YEAR ____________
C. Is all activity performed on a farm? YES
NO
If NO, what percentage is? __________ Please explain in 13A on page 2.
Must be signed by owner, partner, authorized limited liability company member or manager, or officer of the corporation.
Signature ________________________________________ Title ______________________________________ Date ______________________
PLEASE COMPLETE PAGE 2.
FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.
LB-0441
(Rev. 09
)
RDA 1559
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Parent category: Legal