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

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NYS-100A (02/13) page 2
11. Required Addresses
11a. 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 11d below.
Street or PO Box: _______________________________________________________________________________
City: ______________________________________________________ State: _________ ZIP Code: ____________
11b. Physical Address: This is the physical location of your business, if different from the mailing address in 11a.
Street: ________________________________________________________________________________________
City: ______________________________________________________ State: _________ ZIP Code: ____________
11c. Location of Books/Records: This is the physical location where your Books and Records are maintained.
Same as 11a
Same as 11b
Other – please complete
C/O: _________________________________________________________________________________________
Street: ________________________________________________________________________________________
City: ______________________________________________________ State: _________ ZIP Code: ____________
Additional Addresses
11d. 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 :________________
11e. 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.
Same as 11d
Other – please complete
C/O: _________________________________________________________________________________________
Street: ________________________________________________________________________________________
City: ______________________________________________________ State: _________ ZIP Code: ____________
12. Complete the information requested below for the owner, partners (including partners of LLP or RLLP), members (of LLC or PLLC) or
Corporate officers.
Name
Social Security Number
Title
Residential address

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