REPORT FOR SEASONAL DETERMINATION                                                INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
        State Form 15672 (R4/10-09), DWD Form 2003                                            10 N. SENATE AVE., RM SE204
                                                                                              INDIANAPOLIS  IN  46204-2277
                                                                                         Local: (317) 233-6715  Toll Free: 1-800-437-9136  Fax: 317-233-2706
   . Pursuant to Indiana Code 22-4-7-3, the undersigned Employer hereby makes application to become a Seasonal Employer for all or designated portions of its
     Indiana operations.  This form must be updated every two years to keep your Seasonal Determination active.

                                                                                         Date:

1. Indiana SUTA No.:                                                     (             ) FEIN:                            -

•  Legal Name of Employing Unit

•  d/b/a

•  Business Address                                                                                                        PO Box

   City                                            State                                      ZIP Code                             -

   Describe the nature of your business: 

2. List below the name and location of each distinct and segregable portion of your business that you wish to be claimed as
   Seasonal (attach additional sheets if you have more than seven (7) units). 

                    NAME                                                                      LOCATION

   A.

   B.

   C.

   D.

   E.

   F.

   G.

3. Describe the nature of the business that you consider Seasonal under Item 2, and indicate ACTUAL DATES of Seasonal
   operating period (must be less than 26 weeks).
                    NATURE OF OPERATION                                                                                    OPERATING PERIOD

   A.

   B.

   C.

   D.

   E.

   F.

                               (please complete the reverse side of this report)

   REPORT FOR SEASONAL DETERMINATION  (continued)
                                                                                   Account Number

4. List job titles or classifications which are considered Seasonal under Item 2 and the number of Seasonal employees. 

         JOB TITLE OR CLASSIFICATIONS                                              NUMBER OF SEASONAL EMPLOYEES

   A.

   B.

   C.

   D.

   E.

   F.

   G.

   Describe any of your operations that normally extend more than 25 weeks:
5.

6. List your job titles or classifications that normally extend more than 25 weeks.

7. I hereby certify that the foregoing information is true and correct and that I am authorized to execute this report on behalf
   of the employer named above.

                                          Date
                                          (                )                      -
   Signature of Authorized Representative Telephone Number
                                          (                )                      -
   Title                                  FAX Number