GEORGIA DEPARTMENT OF LABOR
                                                                                                                                                                                                                                   SUITE 850 - 148 ANDREW YOUNG INTERNATIONAL BLVD NE - ATLANTA, GA 30303-1751
                                                                                                                                                                                                                                                                                                                                              EMPLOYER STATUS REPORT

READ INSTRUCTIONS BEFORE COMPLETION OF FORM
                                                                                                                                           1. ENTER OR CORRECT BUSINESS NAME AND ADDRESS

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               RETURN ORIGINAL WITHIN 10 DAYS

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               GEORGIA DOL
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               ACCOUNT NUMBER
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               _
                                                                                                                                           3. TRADE NAME                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       (If already assigned)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2. TYPE OF ORGANIZATION
                                                                                                                                           4. PRINCIPAL BUSINESS,                                                             Street Address                                                                                                                                                                                                                                                                                                                                                                                                                                     Individual Partnership                                        Corporation Nonprofit org. 
                                                                                                                                              FARM OR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Limited Liability CO. (LLC) 
                                                                                                                                              HOUSEHOLD
                                                                                                                                              LOCATION IN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Other (specify)________________________
                                                                                                                                              GEORGIA   (Do not use a                                                         City                                                                                                                                                                                                                                                                                            Zip Code                                                                                                                                                County                                                   Telephone Number
                                                                                                                                              P. O. Box number)                                                                                                                                                                                         GA                                                                                                                                                                                                                                                                                                                                                                                     (         )

                                                                                                                                                  5.   WITHINEMPLOYINGDATE FIRSTSTATEWORKERSBEGANOF GA.                                         DATEFIRSTPAYROLLOFGA.                                                                                          6.FORUNEMPLOYMENTAREFEDERAL   YOU LIABLEYES   TAX?NO                                                                                                                                                                                                                                                                         NUMBERFEDERALI. D.                                 _
                                                                                                                                           7. HAVE YOU..........                                                                                                           DATE ACQUIRED                                                                                                                                                                                                                                                                                                                                                                                                    DID YOU ACQUIRE..........
                                                                                                                                                                                                                                                                           OR CHANGED
                                                                                                                                           Acquired another business?     Yes     No                                               =            =                                                                                                                                                                                                                                                                                                                                                                                                                                           =All of Georgia operations?
                                                                                                                                                                                                                                                                           PREDECESSOR'S
                                                                                                                                           Merged with another business? Yes     No                                                =            =                          ACCOUNTGEORGIA DOLNUMBER                                                     ======_                                                                                                                                                                                                                                                                                                                    =  =     =(90%Substantiallyor more)all of Georgia operations

                                                                                                                                           partnership?                   Formed a corporation or Yes     No                       =            =                          HAVEOWNERDOESEMPLOYEES?THECONTINUEFORMERTO      Yes       No                                                                                                                                                                                          =                                                                                                                                             =            =Part of Georgia operations (less than 90%)
                                                                                                                                           Made any other change in the
                                                                                                                                           ownership of your business?    Yes     No    If yes, explain                            =            =
                                                                                                                                           FROM WHOM? (Organization name, including trade name)                                                                                                                                                         ADDRESS

    8.     DidinIF20YOUyou,differentHADor doPRIVATEcalendaryou expectweeksBUSINESSto employduringEMPLOYMENT:ataleastcalendaroneyear?worker                                                                                                                                                                                                       Yes*=  No=                                                         9.      ofDidIF$1,000YOUyou,HADorordomoreDOMESTICyouinexpectany calendartoEMPLOYMENT:pay cashquarter?wages                                                                                                                                                                                                                             Yes*=No=
                                                                                                                                                                                                   * If yes, show date the 20th week first occurred or will occur:                                                                                                                                                                                                                                                             * If yes, show date this first occurred or will occur:
                                                                                                                                                                                                           Did you, or do you expect to have a                                                                                                   Yes* = No =                                                        10. IF YOU HAD AGRICULTURAL EMPLOYMENT:    Did you, or do you expect to employ 10 or more agriculturalYes* = No =
                                                                                                                                                                                                           quarterly payroll of $1,500 or more?                                                                                                                                                                         workers in 20 different calendar weeks during a calendar year?
                                                                                                                                                                                                   * If yes, show date this first occurred or will occur:                                                                                                                                                                                                                                                                      * If yes, show date the 20th week first occurred or will occur:

                                                                   11.    FROMDidIF YOUyou,INCOMEorAREdoAyouNONPROFITTAXexpectUNDERto employIRSORGANIZATIONCODEfour or501(c)(3):moreEXEMPT                                                                                                                                                       Yes*=  No=                                                                                                                                                                    * If yes, show dateDidpayrollthisyou,offirstor$20,000dooccurredyouorexpectmoreor willtoinoccur:haveany calendara gross cashquarter?agricultural                                                                             Yes*=No=
                                                                   workers in 20 different calendar weeks during a
                                                                   calendar year?                                                                                                                                             (ATTACH COPY OF 501( )(3) EXEMPTION LETTER)c                                                                                                                                                         12. HOW MANY EMPLOYEES do you have (or anticipate
                                                                                                                                                                                                   * If yes, show date the 20th week first occurred or will occur:                                                                                                                                                                                                                                                                                                                                                          when in full operation)?

                                                               INFORMATIONABOUT                                                                                                                             Name                                                                                                                                                                                                                   PERSONABOUTINFORMATION                                                                                                                                                                                                                      Name
                                                               OWNER,                                                                                                                                       Social Security                                                                                                                                                                                                        OR FIRM                                                                                                                                                                                                                                     Address
                                                               PARTNERS,ALL                                                                                                                                 Number                                             _                                                                          _                                                                                        WHOMAINTAINS

                                                               (ATTACHOROFFICERPRINCIPAL                                                                                                                    Residence Address                                                                                                                                                                                                      OFRECORDSFINANCIALBUSINESS                                                                                                                                                                                                                  City
                                                               ADDITIONAL                                                                                                                                   City                                                                                                                                                                                                                                                                                                                                                                                                                                                               State   Zip Code            Telephone
                                                               SHEET, OR
                                                               SHEETS, IF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    (        )
                                                                                NECESSARY)                                                                                                                  State      Zip Code                                                                                                        CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those contained
                                                                                                                                                                                                                                                                                                                                       in any attached sheets signed by me are true and correct, and that I am authorized to execute this report on
                                                                                                                                                                                                                                                                                                                                       behalf of the employing unit. This report must be signed by owner, partner or principal officer.
                                                                                                                                                                                                            Telephone                                                                                                                  Signature                                                                                                                                                                                                                                                                                                                                      Title                                                                Date
                                                                                                                                                                                                            (        )
                                                                                                                                                                                                                                                                                                                           PLEASE COMPLETE INDUSTRY INFORMATION                                                                                                                                                                                                                                                                                                                                                                                           DOL-1N  (R-3/13)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           TA489Y

                                                                                                                                                                                                                          (CONTINUED)
NATURE OF BUSINESS: Information is required on all items. Attach additional sheets, if necessary.
A. How many Georgia locations do you operate?                                                                                                                                                                                                                                     C.                                                                                                                                                            Enter in order of importance and indicate
   Provide the following information for each location, attaching additional                                                                                                                                                                                                                                                                                                                                                                          approximate % of total annual income derived 
   sheets if necessary.                                                                                                                                                                                                                                                                                                                                                                                                                         from each:
B. Checkbusinesstheactivities:box that best describes the industry that relates to your                                                                                                                                                                                                                                                                                 PrincipalRendered*Service(s)                                                                                                OR     Mfg.    Grown   PrincipalSoldProduct(s)
                                            Agriculture                                                                                                                 ManufacturingTransportation                                                                                                                                                                                                                                                                                                                                               %

                                            Residential___%MiningSpeculativeGeneralConstructionForestryFishingContractorsBuilding(specify):Commercial___%Industrial___% RealWholesalePublicRetailFinanceCommunicationInsuranceEstateTradeUtilitiesTradeD. If this report includes establishment(s) that only* If Transportation-Trucking, indicate if interstate carrierperformprovided. indicateservicesChecktheforprimaryotheras manyunitstypeasofofapply:theservicecompany,or support                                                          %%
                                            Special Trade Contractor (specify plumbing,                                                                                 Services                                                                                                  1.                                                                                    Central Administration 3.Storage (warehouse)
                                            etc.,)_________________                                                                                                     Public Administration                                                                                     2.                                                                                    Research,development, 4.                                                                                                    Other: (specify),
                                            Heavy Construction (specify cable, highway,                                                                                 Private Household                                                                                                                                                                                                                                                                                                and testing
                                            etc.,)_________________                                                                                                     Employer 
                                                                                                                                                         FOR ASSISTANCE, call the Industry Classification Unit, (404) 232-3875
IMPORTANT - This report must be filed! The law provides that all employing units shallfileareportofitsemploymentduringacalendaryear.Forthe
purpose of aiding you in complying with OCGA Section 34-8-121 of the Employment                                                                                                                                                                                                                                  Security Law, thisformhas                                                                                                                                                             beenprepared to                            assist you in
furnishingtherequiredinformation.Answerallquestionsfullyandifadditionalspaceisnecessaryunderanyitem,attachsignedanddatedsheetswhich
bearthewords"SupplementtoFormDOL-1N."
Each false statement or willful failure to furnish  this report ispunishableasacrime.  Each dayofsuchfailure or
offense.
TheGeorgiaEmployerStatusReportisrequiredofallemployershavingindividualsperformingservicesinGeorgiaregardlessofnumberordurationof
time.
ThefilingofthisformisrequiredatthetimeyourbusinessfirsthadindividualsperformingserviceinGeorgia,orwhenyouacquiredanotherlegalentity,
andmayalsoberequiredagainuponrequest.
NOTE:                                                                                                                               Disclosureofyoursocialsecuritynumberismandatory.Itwillbeusedforthepurposeofidentificationanditisrequiredunderthe
                                                                                                                                    authorityof42U.S.C.Section405(c)(2)(C)andOCGASection 34-8-121.

                                                                                                                                                                                                                          INSTRUCTIONS
                                                                                                                                                                        (NUMBERS CORRESPOND TO ITEMS ON FORM)
1.                                                                                                                    Enterorcorrectnameandaddressofindividualowner,partners,corporationororganization.Thisistheaddresstowhichyouauthorizeusto
                                                                                                                      mailallreports,correspondence,etc.IfyouhavealreadybeenassignedaGeorgiaDepartmentofLaborAccountNumber(Ga.DOLAcct.No)by
                                                                                                                      thisDepartment,pleaseinsertthenumber.
2.                                                                                                                    Indicate by check mark type of organization. If a nonprofit organization, attach copy of I.R.S. letter exempting theorganizationfromFederal
                                                                                                                      IncomeTaxunderSection501(c)(3)ofInternalRevenueCode.
3. Tradenamebywhichbusinessisknownifdifferentthan1.
4.                                                                                                                    Physicallocationofbusiness,farmorhouseholdinGeorgiaifdifferentthan1.Pleaseincludetelephonenumberwithareacode.
5.                                                                                                                    EnterthefirstdateofemploymentinGeorgiaandthefirstdateofGeorgiapayroll.
6.                                                                                                                    IfyouaresubjecttotheFederalUnemploymentTaxAct,andarerequiredtofileFederalForm940,answerthisquestion"yes".Besuretoenter
                                                                                                                      yourFederalEmployerIdentificationNumberwhetheranswered"yes"or"no".
7. Answerthisquestionifyouacquiredthisbusinessfromanotheremployerorifafteryoubeganemployingworkersyouhaveacquiredother
                                                                                                                      businesses;mergedwithotherbusinesses;formedordissolvedpartnerships,corporations,professionalassociations;orifanyotherchangein
                                                                                                                      the ownership of the business has occurred. Indicate the date of acquisition or change and provide all information concerning the previous
                                                                                                                      owner'sname,tradename,addressandDOLAccountNumber.Indicatebycheckingtheappropriateblocktheportionofthepreviousowner's
                                                                                                                      businessinvolvedintheacquisitionorchange.Notransferofexperienceratinghistorycanbemadeunlessinformationconcerningtheprevious
                                                                                                                      ownerisprovided.
8.                                                                                                                    PrivateBusinessEmployment-Mostemploymentisconsideredprivatebusinessemployment.Thisincludesalltypesofworkexceptdomestic
                                                                                                                      servicesuchasmaids,gardeners,cooks,etc.,agriculturalserviceandserviceperformedforgovernmentalornonprofitorganizations.
9.                                                                                                                    Domestic employment includes all service for a person in the operation and maintenance of a private household, local college club or local
                                                                                                                      chapterofacollegefraternityorsororitysuchaschauffeurs,cooks,babysitters,gardeners,maids,butlers,privateand/orsocialsecretaries,
                                                                                                                      etc.Ifyouhadsuchemployment,consideronlycashpaymentsmadetoallindividualsperformingdomesticservicestodetermineif$1,000or
                                                                                                                      morecashwageswerepaidinanycalendarquarterduring1977andsubsequentquarters.
10. Consideronlycashpaymentsmadetoallindividualsperformingagriculturalservicestodetermineif$20,000ormorecashwageswerepaidin
                                                                                                                      anycalendarquarterduring1977andsubsequentquarters.
11.                                                                                                                   AnswerthisquestiononlyifthisbusinessisanonprofitorganizationexemptfromFederalIncomeTaxunderSection501(c)(3)oftheInternal
                                                                                                                      RevenueCode.AttachacopyoftheI.R.S.lettergrantingthisexemption.NonprofitorganizationswithtaxexemptionsotherthanunderSection
                                                                                                                      501(c)(3)shouldanswerquestion8,PrivateBusinessEmployment.
12. Self-explanatory.
                                                                                                                                                         FOR ASSISTANCE, call the Adjudication Section, (404) 232-3301
                                                          RETURN ORIGINAL WITHIN TEN (10) DAYS TO:                                                                                                                                        OR                                                                                                                                                                                                                                                        FAX TO:
                                                                   Georgia Department of Labor                                                                                                                                                                                                                                                                                                                                                                                                      Adjudication Section
                                                                   P O Box 740234                                                                                                                                                                                                                                                                                                                                                                                                                   404-232-3285
  Atlanta, GA 30374-0234
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