Form 60-0126 - Report To Determine Liability - 2006 Page 2

ADVERTISEMENT

INSTRUCTIONS FOR COMPLETING THE BOXES BELOW
Enter a “CHECK MARK” in each calendar week in which one or more “IOWA EMPLOYEES” performed services for this organization for any part of any day dur-
ing the current and preceding calendar year. Include full and part-time employees, corporate officers, members of limited liability companies, students, traveling
or city salespersons, and commission or agent drivers (other than milk) performing services for you in Iowa. Include all Iowa employment if in more than one loca-
tion within the State. Iowa employers MUST include U.S. Citizens performing services for them in a foreign country (except Canada and the Virgin Islands).
FOR AGRICULTURE EMPLOYMENT PLEASE LIST THE NUMBER OF EMPLOYEES FOR EACH WEEK INSTEAD OF THE CHECK MARK.
CURRENT YEAR_______
FEB
WEEK
JAN
MAR
APR
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
1st
ENTER A CHECK
2nd
OR GIVE THE NUMBER
3rd
OF EMPLOYEES FOR
4th
EACH WEEK.
5th
(SEE INSTRUCTIONS ABOVE)
PRECEDING YEAR_______
WEEK
JAN
FEB
MAR
APR
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
1st
ENTER A CHECK
2nd
OR GIVE THE NUMBER
3rd
OF EMPLOYEES FOR
4th
EACH WEEK.
5th
(SEE INSTRUCTIONS ABOVE)
COMPLETE QUESTIONS 14-17 IF YOU HAVE ACQUIRED, PURCHASED, LEASED, OR ASSUMED ALL OR ANY PART OF
AN EXISTING IOWA BUSINESS.
LEGAL DATE OF
PURCHASE OF EXISTING
REORGANIZATION OF EXISTING
OTHER, PLEASE EXPLAIN
14. INDICATE
BUSINESS
BUSINESS
TRANSACTION:
__________________________
NATURE OF
INCORPORATION OF EXISTING
MERGER WITH EXISTING BUSINESS
TRANSACTION
__________________________
BUSINESS
DBA OR TRADE NAME, IF DIFFERENT FROM LEGAL NAME:
15. PREVIOUS OWNER’S LEGAL BUSINESS OR INDIVIDUAL NAME:
FORMER IOWA
UNEMPLOYMENT
ACCOUNT NUMBER
STREET ADDRESS, CITY, STATE & ZIP CODE+4
(IF KNOWN)
__________________________
TELEPHONE NUMBER (+AREA CODE)
CONTACT PERSON’S NAME AND TITLE
16.
DID YOU ACQUIRE SUBSTANTIALLY ALL THE IOWA BUSINESS OF THE EMPLOYER NAMED IN NUMBER 15?...............
YES
NO
IF “YES”, AND YOU ALREADY HAVE AN ACTIVE ACCOUNT, DO YOU WANT THE RATE RECOMPUTED FOR THE BALANCE
YES
NO
OF THE YEAR IN WHICH YOU PURCHASED THE BUSINESS? .........................................................................................................................................................................
IF “YES”, AND YOU DO NOT HAVE AN ACTIVE ACCOUNT, GO TO 18.
IF “NO”, PLEASE COMPLETE QUESTION 17 OF THIS SECTION.
17.
IF YOU DID NOT ACQUIRE SUBSTANTIALLY ALL OF THE IOWA BUSINESS OF THE EMPLOYER NAMED IN NUMBER 15,
WAS THE PART ACQUIRED A CLEARLY SEPARABLE AND IDENTIFIABLE PORTION? ............................................................
YES
NO
YES
NO
IF “YES”, DO YOU WISH A PARTIAL TRANSFER OF EXPERIENCE FROM THE ACCOUNT OF THE PREVIOUS OWNER? .........................................................................
NOTE: A PARTIAL TRANSFER OF EXPERIENCE MUST BE REQUESTED WITHIN 90 DAYS OF THE TRANSFER OF BUSINESS.
18. IF AN OUTSIDE FIRM IS USED, NAME AND MAILING ADDRESS OF
19. IF IT IS DETERMINED YOU ARE EXEMPT FROM THE PROVISIONS
YOUR ACCOUNTANT OR TAX FILING FIRM (Zip Code+4)
OF THE IOWA EMPLOYMENT SECURITY LAW, DO YOU WISH TO
YES
NO
VOLUNTARILY ELECT TO BECOME SUBJECT?
I DECLARE UNDER PENALTIES PROVIDED BY LAW,
THAT THE FOREGOING STATEMENTS AND ATTACHED SCHEDULES ARE
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
ABOVE FIRM’S TELEPHONE NUMBER (+Area Code)
SIGNATURE (AUTHORIZED REPRESENTATIVE)
20. NAME AND ADDRESS OF YOUR BANK (Zip Code+4)
DATE
TITLE
TELEPHONE NUMBER
(+AREA CODE)
DATE
IOWA WORKFORCE DEVELOPMENT FIELD AUDITOR
SAVINGS
CHECKING
This form is available at no cost to the public from Iowa Workforce Development.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 4