Reset Form

                     INDIANABUSINESSLOCATIONS                                                                                         
                                                                                                                                      
                     StateForm48812(R2/4        ‐ 15)                                                                                 
                     INDIANADEPARTMENTOFWORKFORCEDEVELOPMENT                                                                          
                     10NSenateAveRMSE202               
                     Indianapolis,IN46204   2277‐     
                     ConfidentialrecordpursuantToIC4       ‐ ‐ 1 16,IC22   4 196‐ ‐ ‐  
               
*ThisagencyisrequestingdisclosureofSocialSecurityNumbers(SSNs)inaccordancewithIC4                  1 8 1;disclosureismandatoryandthisrecordcannotbeprocessedwithoutit.    ‐ ‐ ‐                     

IMPORTANT:  EmployersthathavemultipleworklocationsinIndianaarerequiredtoprovidetheaddressofthelocationswherework                                                                                      
isbeingperformed.Employersmayalsodesignateoneeach(1)specificaddresstobeusedforbenefitnotificationsorcollections                                                                                    
noticesthatis,orisnot,anIndianaworksitelocation.AllotheraddressesshouldbeinIndiana.Thisformisusedtocreateoramend                                                                                     
locationcodesfortheemployer.     IfyouareasingleemployingunitreportingformultipleFEINs,thisformisrequiredforproper                                                                               
administrationoftheaccount.     Pleasegoto                  www.in.gov/dwd/SUTA.htm  foradditionalinformationorclarification.                              
                                            SECTIONONE–IDENTIFICATIONOFTHEEMPLOYER                                                    
WhatistheSUTAnumbercurrentlyassignedtothebusinessyouarereporting?                                       
 
WhatisthenameofthisbusinessasregisteredwithIDWD?                                         

 WhatistheFEINnumberofthisemployerasregisteredwithIDWD?                                       
 Selectfilingtype:            CreateLocations                                                   AmendLocations 

                     SECTIONTWO–LOCATIONS                                               (Additionalformsmaybecompletedasneeded.)                   
 1.Name    
   Currentlocationcode(amend):                                                           FEINifdifferentfromPrimaryFEIN:       
  
   Street 

    City                                                                                                                                                 State

    ZIP                                                                                                   US         Canada          Mexico       Other    
 
                                                                                                                   Extor   
 Telephone                                                                                                         Name                                                                         
 
              Typeoflocation:                        IndianaWorkSite                                 BenefitMailing                    CollectionMailing 
 2.Name    
   Currentlocationcode(amend):                                                           FEINifdifferentfromPrimaryFEIN:       
  
   Street 

    City                                                                                                                                                 State

    ZIP                                                                                                   US         Canada          Mexico       Other    
 
                                                                                                                   Extor   
 Telephone                                                                                                         Name                                                                         
 
              Typeoflocation:                        IndianaWorkSite                                 BenefitMailing                    CollectionMailing 
 3.Name    
   Currentlocationcode(amend):                                                           FEINifdifferentfromPrimaryFEIN:       
  
   Street 

    City                                                                                                                                                 State

    ZIP                                                                                                   US         Canada          Mexico       Other    

                                                                                      Extor   
 Telephone                                                                            Name                                                                  
 
              Typeoflocation:              IndianaWorkSite                   BenefitMailing                    CollectionMailing 
  4.Name     
        Currentlocationcode(amend):                           FEINifdifferentfromPrimaryFEIN:           
        
   Street 

        City                                                                                                                                          State

        ZIP                                                                       US          Canada           Mexico             Other
  
                                                                                         Extor   
   Telephone                                                                             Name 
              Typeoflocation:              IndianaWorkSite                   BenefitMailing                    CollectionMailing 
  5.Name     
        Currentlocationcode(amend):                           FEINifdifferentfromPrimaryFEIN:           
        
   Street 

        City                                                                                                                                          State

        ZIP                                                                       US          Canada           Mexico             Other
  
                                                                                         Extor   
   Telephone                                                                             Name 
              Typeoflocation:              IndianaWorkSite                   BenefitMailing                    CollectionMailing 
        
                                                 SECTIONFOUR–AUTHORIZATION                       
  
  Providethenameandcontactinformationforthepersonwhopreparedthisformforsignature.                 
 First                                                               Last 
 Name                                                                Name 
  
 Telephone                                                                            Agent                 Employee

 Preparer’sSignature:                                                                                 Date                  /                          /
  
  Providethenameofthepersonwhoistheresponsiblepartyfordisclosuresregardingthisentity:                   DonotidentifyathirdpartyAgent.                   
 First                                                               Last  
 Name                                                                Name 
  
 Telephone                                                                                    Title
  
   ResponsibleParty’sSignature:                                                                                     Date             /                      /
  
 IMPORTANT:Bysigningthisform,youarecertifyingthattheinformationcontainedhereinistrueandaccuratetothebestofyourknowledge                                        
 andbelief.  Youfurtheraffirmthatyouareapersonofsufficientauthoritywithregardtothenamedentitytofilethisdocumentandtobindthe                                     
 businessbytheinformationprovidedincludingallrequiredattachmentsanddisclosuresasindicated.                 
   
 Mailcompletedformsto:                IDWD–EmployerStatusReports                            Fax:317     233‐ 2706‐      
                                      10NSenateAveRmSE202                                   Questions:800437        ‐  9136(2)‐    
                                      Indianapolis,IN46204   2277‐                          Handbook: www.in.gov/dwd