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

                                                                    EMPLOYER STATUS REPORT

READ INSTRUCTIONS ON REVERSE SIDE
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
                                                                                                     Individual         Partnership       Corporation                    Nonprofit org.
4. PRINCIPAL BUSINESS,          Street Address                                                       Limited Liability CO. (LLC)
   FARM OR
   HOUSEHOLD                                                                                         Other (specify)
   LOCATION IN
   GEORGIA                      City                                                  Zip Code                County                      Telephone Number
   (Do not use a
   P. O. Box number)                                                       GA                                                          (         )
5. DATE FIRST BEGAN                                  DATE OF                   6. ARE YOU LIABLE                    FEDERAL
   EMPLOYING WORKERS                                 FIRST GA.                  FOR FEDERAL      Yes     No         I.D.
   WITHIN STATE OF GA.                               PAYROLL                    UNEMPLOYMENT TAX?                   NUMBER
7. HAVE YOU...                                             DATE ACQUIRED                                            DID YOU ACQUIRE...
                                                           OR CHANGED
Acquired another business?             Yes  No                                                                          All of Georgia operations?
                                                           PREDECESSOR’S
                                                           GEORGIA DOL                                                  Substantially all of Georgia operations
Merged with another business?          Yes  No             ACCOUNT NUMBER                                               (90% or more)
                                                           DOES THE FORMER OWNER
Formed a corporation or                                    CONTINUE TO                                                  Part of Georgia operations (less than 90%)
partnership?                           Yes  No             HAVE EMPLOYEES?      Yes              No

Made any other change in the
ownership of your business?            Yes  No       If yes, explain
FROM WHOM? (Organization name, including trade name)                           ADDRESS

8. IF YOU HAD PRIVATE BUSINESS EMPLOYMENT:                                            9. IF YOU HAD DOMESTIC EMPLOYMENT:
   Did you, or do you expect to employ at least one worker                            Did you, or do you expect to pay cash wages
   in 20 different calendar weeks during a calendar year?      Yes *       No         of $1,000 or more in any calendar quarter?                          Yes*                   No
   * If yes, show date the 20th week first occurred:                                  * If yes, show date this first occurred:
                                                                                      10.IF YOU HAD AGRICULTURAL EMPLOYMENT:                              Yes*                   No
   Did you, or do you expect to have a                                                Did you, or do you expect to employ 10 or more agricultural
   quarterly payroll of $1,500 or more?                        Yes *       No         workers in 20 different calendar weeks during a calendar year?
   * If yes, show date this first occurred:                                           * If yes, show date the 20th week first occurred:
11.IF YOU ARE A NONPROFIT ORGANIZATION EXEMPT                                         Did you, or do you expect to have a gross cash agricultural
   FROM INCOME TAX UNDER IRS CODE 501(C)(3):                   Yes *       No         payroll of $20,000 or more in any calendar quarter?                 Yes*                   No
   Did you, or do you expect to employ four or more                                   * If yes, show date this first occurred:
   workers in 20 different calendar weeks during a
   calendar year? (ATTACH COPY OF 501(C)(3) EXEMPTION LETTER)                         12.HOW MANY EMPLOYEES do you have, (or anticipate
   * If yes, show date the 20th week first occurred:                                  when in full operation)?
                Name
INFORMATION                                                                           INFORMATION    Name
ABOUT                                                                                 ABOUT
OWNER,          Social Security                                                       PERSON
                Number                                                                OR FIRM        Address
ALL                                                                                   WHO
PARTNERS,       Residence Address                                                     MAINTAINS
OR PRINCIPAL                                                                          FINANCIAL      City
OFFICER                                                                               RECORDS
(ATTACH                                                                               OF BUSINESS
                City
ADDITIONAL                                                                                           State          Zip Code                     Telephone
SHEET,OR                                                                                                                                         (       )
SHEETS, IF      State           Zip Code                             CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those contained
NECESSARY)                                                           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 ON REVERSE SIDE.                                                                    DOL-1A (R-5/05)
                                                                                                                                                                                 TA489A

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(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. Check the box that best describes the industry that relates to your Principal Service(s) OR Principal Product(s)
business activities: Rendered* Mfg. Grown Sold
Agriculture Manufacturing %
Forestry Transportation %
Fishing Communication %
Mining Public Utilities * If Transportation - Trucking, indicate if interstate carrier
Construction (specify): Wholesale Trade
General Contractors Industrial % Retail Trade D. If this report includes establishment(s) that only
Residential % Commercial % Finance perform services for other units of the company,
Speculative Building Insurance indicate the primary type of service or support
Special Trade Contractor (specify plumbing, Real Estate provided. Check as many as apply:
etc.,) Services
Heavy Construction (specify cable, highway, Public Administration 1. Central Administration 3. Storage (warehouse)
etc.,) Private Household 2. Research, development, 4. Other: (specify)
Employer and testing

FOR ASSISTANCE, call the Industry Classification Unit, (800) 338-2082
IMPORTANT - This report must be filed! The law provides that all employing units shall file a report of its employment during a calendar year. For the purpose
of aiding you in complying with OCGA Section 34-8-121 of the Employment Security law, this form has been prepared to assist you in furnishing the required
information. Answer all questions fully and if additional space is necessary under any item, attach signed and dated sheets which bear the words Supplement
to Form DOL-1.”

Each false statement or willful failure to furnish this report is punishable as a crime. Each day of such failure or refusal constitutes a separate offense.

The Georgia Employer Status Report is required of all employers having individuals performing services in Georgia regardless of number or duration of time.

The filing of this form is required at the time your business first had individuals performing service in Georgia, or when you acquired another legal entity, and
may also be required again upon request.

NOTE: Disclosure of your social security number is mandatory. It will be used for the purpose of identification and it is required under the authority of
42 U.S.C. Section 405(2)(c) and OCGA Section 34-8-121(a).

INSTRUCTIONS
(NUMBERS CORRESPOND TO ITEMS ON FORM)

1. Enter or correct name and address of individual owner, partners, corporation or organization. This is the address to which you authorize us to mail all
reports, correspondence, etc. If you have already been assigned a Georgia Department of Labor Account Number (Ga. DOL Acct. No) by this
Department, please insert the number.
2. Indicate by check mark type of organization. If a nonprofit organization, attach copy of I.R.S. letter exempting the organization from Federal Income
Tax under Section 501(c)(3)of Internal Revenue Code.
3. Trade name by which business is known if different than 1.
4. Physical location of business, farm or household in Georgia if different than 1. Please include telephone number with area code.
5. Enter the first date of employment in Georgia and the first date of Georgia payroll.
6. If you are subject to the Federal Unemployment Tax Act, and are required to file Federal Form 940, answer this question “yes”. Be sure to enter your
Federal Employer Identification Number whether answered “yes” or “no”.
7. Answer this question if you acquired this business from another employer or if after you began employing workers you have acquired other busi-
nesses; merged with other businesses; formed or dissolved partnerships, corporations, professional associations; or if any other change in the
ownership of the business has occurred. Indicate the date of acquisition or change and provide all information concerning the previous owner’s name,
trade name, address and DOL Account Number. Indicate by checking the appropriate block the portion of the previous owner’s business involved in
the acquisition or change. No transfer of experience rating history can be made unless information concerning the previous owner is provided.
8. Private Business Employment - Most employment is considered private business employment. This includes all types of work except domestic
service such as maids, gardeners, cooks, etc., agricultural service and service performed for governmental or nonprofit organizations.
9. Domestic employment includes all service for a person in the operation and maintenance of a private household, local college club or local chapter of
a college fraternity or sorority such as chauffeurs, cooks, babysitters, gardeners, maids, butlers, private and/or social secretaries, etc. If you had such
employment, consider only cash payments made to all individuals performing domestic services to determine if $1,000 or more cash wages were paid
in any calendar quarter during 1977 and subsequent quarters.
10. Consider only cash payments made to all individuals performing agricultural services to determine if $20,000 or more cash wages were paid in any
calendar quarter during 1977 and subsequent quarters.
11. Answer this question only if this business is a nonprofit organization exempt from Federal Income Tax under Section 501(c)(3) of the Internal Revenue
Code. Attach a copy of the I.R.S. letter granting this exemption. Nonprofit organizations with tax exemptions other than under Section 501(c)(3)
should answer question 8, Private Business Employment.
12. Self-explanatory.
FOR ASSISTANCE, call the Adjudication Section, (404) 232-3301.
Please RETAIN a copy for your files. RETURN ORIGINAL WITHIN TEN (10) DAYS TO: Georgia Department of Labor
P. O. Box 740234
The enclosed envelope requires postage. Atlanta, GA 30374-0234
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