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                          INDIANA BUSINESS LOCATIONS                                                                                                                            
                                                                                                                                                                                
                          State Form 48812      (R2 / 4    ‐ 15)                                                                                                                
                          INDIANA DEPARTMENT OF           WORKFORCE                     DEVELOPMENT                                                                             
                          10   N Senate Ave   RM SE   202         
                          Indianapolis,   IN 46204 2277‐         
                          Confidential record   pursuant To IC    ‐ ‐ 4 1 16, IC 22   4 19 6‐ ‐ ‐  
                     
 * This agency is   requesting disclosure  of Social   Security   Numbers               (SSNs)  in accordance   with IC 4 1 8 1;    ‐ ‐ ‐  disclosure is mandatory   and this record cannot  be processed without  it.          

 IMPORTANT:  Employers that                   have     multiple       work                 locations in Indiana         are required       to provide              the address        of the locations    where      work         
is being performed.            Employers        may    also     designate                   one each  (1) specific        address     to be used              for benefit      notifications     or collections                
notices that     is,       or is not, an Indiana  worksite         location.                All other   addresses           should be in Indiana.                This form is used       to create     or amend                  
location codes      for the      employer.      If you    are a single                     employing   unit reporting            for multiple              FEINs, this    form is    required      for proper                
administration         of the account.          Please   go to     www.in.gov/dwd/SUTA.htm  for additional information                                                                   or   clarification.         
                                                       SECTION ONE –   IDENTIFICATION OF                                             THE                 EMPLOYER               
 What   is the SUTA    number         currently        assigned       to the   business               you are    reporting?                                                                                         
  
 What   is the name    of   this business       as registered                    with IDWD? 

  What   is the FEIN number           of this   employer          as registered                  with IDWD?                                                                                                           
 Select  filing  type:                        Create Locations                                                   Amend Locations

                          SECTION TWO –   LOCATIONS                                                 (Additional forms             may                    be   completed as needed.)                     
 1.  Name                                                                                                                                                                                                              
        Current location code             (amend):                                                  FEIN   if different from      Primary                  FEIN:      
    
     Street                                                                                                                                                                                                           

         City                                                                                                                                                                                                State         

         ZIP                                           ‐                                                                             US                    Canada              Mexico               Other            
  
                                                                                                                                                          Ext or   
  Telephone                           ‐                                                    ‐                                                              Name                                                              
  
                    Type of   location:                         Indiana Work Site                                           Benefit Mailing                                          Collection Mailing
 2.  Name                                                                                                                                                                                                              
        Current location code             (amend):                                                  FEIN   if different from      Primary                 FEIN:       
    
     Street                                                                                                                                                                                                           

         City                                                                                                                                                                                                State         

         ZIP                                           ‐                                                                             US                    Canada              Mexico               Other            
  
                                                                                                                                                          Ext or   
  Telephone                           ‐                                                    ‐                                                              Name                                                              
  
                    Type of   location:                         Indiana Work Site                                           Benefit Mailing                                          Collection Mailing
 3.  Name                                                                                                                                                                                                              
        Current location code             (amend):                                                  FEIN   if different from      Primary                  FEIN:      
    
     Street                                                                                                                                                                                                           

         City                                                                                                                                                                                                State         

         ZIP                                           ‐                                                                             US                    Canada              Mexico               Other            

                                                                                                          Ext or   
 Telephone                   ‐                    ‐                                                       Name                                                            
 
                   Type of   location:           Indiana Work Site                        Benefit Mailing                            Collection Mailing
 4. Name                                                                                                                                                             
        Current location code     (amend):                                FEIN   if different from Primary   FEIN:        
        
     Street                                                                                                                                                          

         City                                                                                                                                                      State   

        ZIP                                 ‐                                                        US            Canada            Mexico               Other  
  
                                                                                                              Ext or   
   Telephone     ‐    ‐                                                                                       Name                                                        
  
                   Type of   location:           Indiana Work Site                        Benefit Mailing                            Collection Mailing
 5. Name                                                                                                                                                             
        Current location code     (amend):                                FEIN   if different from Primary   FEIN:        
        
     Street                                                                                                                                                          

        City                                                                                                                                                       State   

        ZIP                                 ‐                                                        US            Canada            Mexico               Other  
  
                                                                                                              Ext or   
   Telephone                      ‐                           ‐                                               Name                                                        
  
                   Type of   location:           Indiana Work Site                        Benefit Mailing                            Collection Mailing
        
                                                           SECTION FOUR –   AUTHORIZATION                            
  
  Provide the name  and contact   information    for the person  who prepared    this form for signature.               
 First                                                                              Last 
 Name                                                                               Name                                                                             
  
 Telephone                        ‐                           ‐                                            Agent                 Employee                            
  
 Preparer’s Signature:                                                                                                   Date                  /                 /         
  
  Provide the name  of   the person who is the   responsible party for disclosures  regarding   this entity:              Do not    identify a   third party Agent.  
 First                                                                              Last  
 Name                                                                               Name                                                                             
  
 Telephone                        ‐                            ‐                                                   Title 
  
 Responsible Party’s Signature:                                                                                                          Date              /              /   
  
 IMPORTANT: By signing       this form, you are certifying that the information     contained  herein is true and   accurate     to the best   of your knowledge            
 and belief. You  further affirm  that you are a person   of sufficient   authority with regard to the named   entity   to file this document     and  to bind the           
 business by   the information    provided including all required   attachments     and disclosures  as indicated.            
   
 Mail completed forms        to:        IDWD   – Employer Status          Reports                              Fax: 317    233‐  2706‐     
                                        10 N   Senate Ave    Rm  SE   202                                      Questions: 800 437‐        9136‐   (2)      
                                        Indianapolis,   IN 46204 2277‐                                         Handbook: www.in.gov/dwd