UC-55  REV 6-05 (Page 1)                                               COMMONWEALTH OF PENNSYLVANIA                                                               DEPARTMENT OF LABOR & INDUSTRY                                                               OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES     

                                                                                                                                                                                                                                                                                                                                                                                                                                                                         EMPLOYEE’S NAME, SOCIAL SECURITY NUMBER, 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     WITHOUT, OR BOTH WITHIN AND WITHOUT PENNSYLVANIA                                                                                   FOR EMPLOYEES WHOSE TOTAL SERVICES ARE PERFORMED 

                                                                                                                                                                                                                                                                                                                                                                                                     RESIDENCE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            EMPLOYER’S STATUS REPORT
                                                                                                                                                                                                                                                                                                                                                                                                                            AND                                                                                                            1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            (SEE INSTRUCTIONS ON REVERSE SIDE)

                                                                                                                                                                                                                                                                                                                                                                                                     OPERATIONS IS LOCATED                                               LIST THE STATE IN WHICH 
                                                                                                                                                                                                                                                                                                                                                                                                                            EMPLOYEE’S BASE OF

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2

                                                                                                                                                                                                                                                                                                                                                                                                                            WHICH EMPLOYEE’S WORK
                                                                                                                                                                                                                                                                                                                                                                                                                                                                         LIST THE STATE FROM
                                                                                                                                                                                                                                                                                                                                                                                                     IS CONTROLLED

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PA UC ACCOUNT NUMBER                                                       ADDRESS _________________________________________________________________________                                                                                  EMPLOYER’S NAME _________________________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                            YOU REPORTED AND PAID                        LIST THE STATE IN WHICH
                                                                                                                                                                                                                                                                                                                                                                    EMPLOYEE’S WAGES                 CONTRIBUTIONS ON

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           4

                                                                                                                                                                                                                                                                                                                                                                    PERFORMED SERVICES               IN WHICH THE EMPLOYEE                                               LIST THE NAMES OF ALL 

                                                                                                                                                                                                                                                                                                                                                                                                                            STATES
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           5

                                                                                                                                                                                                                                                                                                                                                                    PERFORMED IN EACH STATE          IN WHICH SERVICES WERE                                              APPROXIMATE NUMBER OF                       SPECIFY THE YEARS AND 
                                                                                                                                                                                                                                                                                                                    YEARS                     WEEKS
                                                                                                                                                                                                                                                                                                                                                   LISTED IN COLUMNS
                                                                                                                                                                                                                                                                                                                                                                                                                            WEEKS
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           6

Article I, Section 4(1)(2)(B) of the Pennsylvania Unemployment Compensation Law provides, in part, as 
follows:

“The term ‘Employment’ shall include an individual’s entire service performed within or both within 
and without this Commonwealth, if - 

        “The service is not localized in any state but some of the service is performed within this 
        Commonwealth and (a) the base for operations or place from which such service is directed 
        or controlled is in this Commonwealth, or (b) the base for operations or place from which such 
        service is directed or controlled is not in any state in which some part of this service is performed, 
        but the individual’s residence is in this Commonwealth. . .”

Section 4(1)(2)(C) provides: “The term ‘Employment’ shall include an individual’s service wherever 
performed within the United States, the Virgin Islands or Canada if - (i) such service is not covered under 
the unemployment compensation law of any other state, the Virgin Islands or Canada, and (ii) the place 
from which the service is directed or controlled is in this Commonwealth.”

                        INSTRUCTIONS FOR FILING THIS FORM

1.  Enter the employee’s full name, Social Security Number, and state in which he/she resides.

2.  The base of operations is the location of more or less permanent nature from which the employee 
starts his/her work, and to which he/she customarily returns to get instructions, replenishes his/her 
stocks, or performs other duties necessary in carrying on his/her work at some other point. It may 
be his/her business office, which may be located where he/she lives, or it may be the place that the 
employment contract specifies as the one to which the employee must go to get his/her instructions.

3.  Place of direction  or control has been defined to mean the place from which the employer directs 
or controls the activities of his employees. It is the place at which the basic authority exists and from 
which the general control emanates.

4.  Enter the name of the state to which you paid contribution on the employee’s wages; if no contribution 
was paid to any state, insert the word “None.”

5.  List the names of all states in which the employee customarily performs some services. If services 
were performed in Pennsylvania, it is to be indicated in this column.

6.  List the years and approximate number of weeks in which the employee performed services in each 
state shown in Column 5.

                        Auxiliary aids and services are available upon request to individuals with disabilities.
                        Equal Opportunity Employer/Program

UC-55  REV 6-05 (Page 2)