Form 309-6701 - Contractor Registration Application/renewal Form/form 60-0126 - Report To Determine Liability Page 6

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Report to Determine Liability
60-0126 (03-12)
Reporting Unit Address: (Where work is performed in Iowa, if different from the primary business address)
If you have more than one location, attach a list providing the full name, address and phone number of each location
.
Unit Number:
Name of Unit:
Address 1:
Iowa
Address 2:
City:
State:
Zip+4/Postal:
Iowa County:
Phone:
Ext:
Registration Reason
Select the statement that best applies to your business.
It has become an Iowa employing entity by reorganizing, acquiring or by assuming all or part of an existing Iowa business.
It has operations in other states and has now begun Iowa employment.
It is a start up Iowa business that has employment.
It is an active Iowa employer, but needs to report a reorganization, acquisition or assumption of all or part of an existing Iowa business.
None of the above. It is seeking contractor registration with Iowa Workforce Development - Division of Labor.
For contractor registration visit:
Liability Information
For the current year and the five previous years, enter the gross quarterly wages paid in Iowa.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Current Year:
Previous Year:
Year:
Year:
Year:
Year:
Enter an "X" in each week in which one or more "Iowa Employees" worked for this organization for any day during the current and five
previous years. Agriculture Employers: List the number of employees for each week instead of an "X".
Week
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Current Year:
1st
2nd
Enter an "X" or enter the number
3rd
of employees for each week.
4th
5th
Week
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Previous Year:
1st
2nd
Enter an "X" or enter the number
3rd
of employees for each week.
4th
5th
Week
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Year:
1st
2nd
Enter an "X" or enter the number
3rd
of employees for each week.
4th
5th
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