Form 2837 - Report To Determine Status - Indiana Department Of Workforce Development
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1
2OFFICE USE ONLY
Original Report
Amended
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
•
10 N. SENATE AVE.
INDIANAPOLIS IN 46204-2277
Status Date
Qualified On
Transfer
Preassigned
(317) 232-7436
REPORT TO DETERMINE STATUS
Payment Method
Under Section
(APPLICATION FOR EMPLOYER NUMBER)
State Form 2837 (R3/2-96)
Business Code
Merit Rate Start Date
•
IF YOU HAVE ACQUIRED ANOTHER BUSINESS AND HAVE ALREADY BEEN ASSIGNED AN
ACCOUNT NUMBER, PLEASE INDICATE THAT NUMBER IN ITEM 1 BELOW.
Country Code
Merit Year Rate
SIC Code
IMPORTANT:
Any Employing Unit which fails to submit any report required within 10 days after
19 ____
_____ %
such request is sent, shall be assessed a penalty of not less than $25.00 (reference Indiana Code
County Code
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_____ %
22-4-19-10). If you are an employer of AGRICULTURAL or DOMESTIC (household) help, do not
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_____ %
complete this form. Please call (317) 232-7436 to obtain the appropriate application.
Size Code
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_____ %
PLEASE TYPE OR PRINT IN INK.
Verified with Sec.
of State
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_____ %
(
)
1. Indiana SUTA Number:
Federal ID Number: __ __-__ __ __ __ __ __ __
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_____ %
Preassn. Ltr. Sent
2. Legal Name of Employing Unit
Merit Rate Requested
Date:
Fed. Cert. Requested
(or d/b/a)
3. Trade Name
Preassigned Verification:
4. Mailing Address
UC-1's Sent
NTR's Needed
Street Address or PO Box
City
State
Audit Examiner
Supervisor Approval
(+4 + 2 + 1)
Indiana County
ZIP Code
NOTES:
__ __ __ __ __ - __ __ __ __ - __ __ - __
Business Telephone Number
FAX Number
(
)
(
)
-
-
Check here if physical location of business is at a different address, or there are additional business locations (atttach a schedule).
State of
(b) Formation date of
(c)
5. (a) Type of organization
(check one)
incorporation:
Corporation
or
Individual
Corporation
Partnership
Partnership:
Employee Leasing/Management Company
(2 letter abbreviation)
mm
dd
yy
Other (Estate, Trust, Receivership) Identify
AND
(b) Date payroll began in Indiana:
6. Primary Indiana business activity:
7. (a) Date operation began in Indiana:
mm
yy
dd
mm
dd
yy
8. Enter the required information for owner, partners or officers. Please attach additional sheet(s) if needed.
Name (please print)
Title
Social Security Number
Telephone Number
-
(
)
-
(
)
-
(
)
9. Enter any account number previously assigned
10. Did you incorporate, purchase, lease or assume all or any part of an
to you by Indiana Dept. of Workforce Dev.
existing Indiana business from another business entity?
No
Yes
Œ
Š
(
)
If "YES", you must complete Section "A" on the back of this report.
11. Has your business had a total Indiana payroll of $1,500.00
12. Has your business had one or more employees any part of a day,
in each of twenty (20) different weeks
(not necessarily
or more in any calendar quarter during the current or
consecutive)
during the current or preceding calendar year?
preceding calendar year?
(Including salaried officers)
Œ
Œ
/
/
/
No
Yes
(Date of 20th week):
No
Yes
(Quarter/Year)
If
"Yes",
please
14. Are you a non-
If "Yes", do you employ 4 or
13. Has your business filed an IRS Form 940, AND
attach a copy of your
profit organization
more individuals any part of a
qualified under the Federal Unemployment Tax Act?
IRS exemption letter,
under IRS Code
week in each of 20 different
Œ
and
call
(317)
501(c)(3)?
weeks of the calendar year?
No
Yes
If "YES", which years:
232-7436 to request
No
Yes
No
Yes
Form 1065.
If you are not currently subject to the laws of Indiana relating
If you are not currently subject to the laws of Indiana relating to
15.
16.
State Unemployment Tax (SUTA), do you wish to file a voluntary
to State Unemployment Tax (SUTA), do you anticipate
election of coverage for your Indiana employee(s)?
qualification during the current calendar year?
Œ
Œ
/
(Quarter/Year)
No
No
Yes
Yes
If "Yes", State Form 9 is required.
I hereby certify that
all information
contained herein is
true, correct and
EMPLOYER'S SIGNATURE
PREPARED BY
complete to the best
Phone
Phone
of my knowledge and
(
)
(
)
DATE
No.
DATE
No.
belief.
CONTINUE ON REVERSE SIDE IF ITEM #10 IS MARKED "YES."
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