Form Nys-100 - New York State Employer Registration For Unemployment Insurance, Withholding, And Wage Reporting Page 2

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NYS 100 page 2
Legal Name: __________________________________ER Number: _________________________
6. Have you acquired the business of another employer liable for NYS Unemployment Insurance?
Yes*
No
/
/
* If Yes, did you acquire
All or
Part?
Date of acquisition:
(mm/dd/yyyy)
-
-
Prior Owner’s: Registration number:
FEIN:
Legal name of business: ______________________________________________________________
Address:___________________________________________________________________________
7. Have you changed legal entity?
Yes*
No
/
/
* If Yes, date of legal entity change:
(mm/dd/yyyy)
-
-
Previous employer’s: Registration number:
FEIN:
Part C – Household Employer of Domestic Services
.
1
Indicate the first calendar quarter and enter the year you paid (or expect to pay) total cash wages of $500 or more:
Jan 1 – Mar 31 (1st)
Apr 1 – Jun 30 (2nd)
Jul 1 – Sep 30 (3rd)
Oct 1 – Dec 31 (4th)
Tax Year
2. Enter the total number of persons employed in your home: ________________________
3. Will you withhold New York State income tax from these employees?
Yes
No
Part D – Required Addresses
1. Mailing Address: This is your business mailing address where your Withholding Tax (WT) and Unemployment
Insurance (UI) mail will be delivered. However, if you elect to have your UI mail directed to an address other than your
place of business, complete number 4 below.
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
2. Physical Address: This is the physical location of your business, if different from the Mailing Address in number 1.
Street: ________________________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
3. Location of Books/Records: This is the physical location where your Books and Records are maintained.
Street: ________________________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
Optional Addresses
4. Agent Address (C/O): Complete this if your UI mail should be sent to an address other than your business address.
C/O: __________________________________________________________________________________________
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
5. LO 400 Form - Notice of Entitlement and Potential Charges Address: If completed, this is where the LO 400 will
be directed. (It is mailed each time a former employee files a claim for Unemployment Insurance benefits.)
C/O: __________________________________________________________________________________________
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
* Refer to NYS – 100 I for instructions.

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