Form 309-6701 - Contractor Registration Application/renewal Form/form 60-0126 - Report To Determine Liability Page 5

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Report to Determine Liability
60-0126 (03-12)
Unemployment Insurance Tax Bureau
1000 E Grand Ave
Des Moines IA 50319-0209
Phone: 888-848-7442 option #3 then option #7
Business Information
Date business began employing
Enter the primary contact information for the business:
workers in Iowa:
First date wages were
Contact Person:
paid in Iowa:
Reset
Select your legal entity type and subtype, if applicable.
Title:
Sole Proprietor
LLC
Conservatorship
Corporation
Indian Tribe
Single Member
Phone:
Ext:
Religious Organization
C-Corporation
Multiple Member
Alternate
Association
Governmental
Phone:
S-Corporation
Ext:
Cooperative
Partnership
Political Subdivison
Email:
General
Federal
Limited (LP)
Military
Legal Business
Limited Liability (LLP)
Other State
Name:
Professional Limited (PLLP)
Other Country
Joint Venture
State of Iowa
DBA:
Trustee
City/County
Is this business a Non-Profit 501(c)(3)?
Yes*
No
Estate
Quasi
Existing UI
*Non-Profit 501(c)(3) Organizations must attach a copy of their Federal Exemption Letter.
FEIN:
Account Number:
Number of Iowa Worksites:
A Federal Employer Identification Number (FEIN) is REQUIRED.
You can apply for a FEIN by contacting the Internal Revenue Service (IRS).
North American Industrial Classification System (NAICS) Information
What is the primary
Enter a description of the primary business activity in Iowa.
business activity in Iowa?
Ownership Information
Owner/Officer/Member/Partner
Phone
SSN/FEIN
Resident Address
Address Information
Primary Business Address:
Primary Mailing Address:
(If different from Primary Business Address)
Address 1:
Address 1:
Address 2:
Address 2:
City:
City:
State:
Zip+4/Postal:
State:
Zip+4/Postal:
County:
Country:
County:
Country:
Phone:
Fax:
Email:
NOTE: Information collected from employers by the Unemployment Insurance Services Division of Iowa Workforce Development may also be
provided to various federal and state agencies as required or permitted by federal and state law.
Equal Opportunity Employer/Program
Page 1 of 4
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