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UC-1 NP (Rev. 4/10)
ABC Over 6 Lag Date EMPLOYER STATUS REPORT For
UNEMPLOYMENT COMPENSATION
Registration Number: IC Under 6 ___________
5 6 Fund Code
For Office Use Only
Status ____________________________________ Typed 2ps __________
Rate(s)____________________________________
Quarter(s)__________________________________ Other ______________________
Date Rec’d Predecessor Reg. No.:
RETURN COMPLETED FORM TO:
FOR NON-PROFIT - 501 (C) (3) EMPLOYER ___________________________
FORM IS TO BE TYPED OR PRINTED IN INK. IF ADDITIONAL SPACE IS REQUIRED, PLEASE ATTACH EXTRA EMPLOYER STATUS UNIT
SHEET. INDICATE COMPANY NAME AT THE TOP OF SHEET AND INCLUDE RESPECTIVE ITEM NUMBER 200 FOLLY BROOK BLVD.
WITH RESPONSE. WETHERSFIELD, CT 06109-1114
TEL. NO. (860) 263-6550 FAX (860) 263-6567
1. Federal Identification Number__________________ Tel. No. ( )______________Email Address:_________________________________________
2. Business or Trade Name ____________________________________________________________________________________________________
3. Name of Owner, Partners, or
Corporate name, if other than above____________________________________________________________________________________________
4. Mailing
address _________________________________________________________________________________________________________________
Number Street or P.O. Box City State Zip Code
5. List Connecticut business locations, if different from above. If mailing address is P.O. Box, please give the physical
location of business
________________________________________________________________________________________________________________________________________
6. Are you a nonprofit organization exempt from federal income tax under Section 501(c) (3) of the Internal Revenue Code?
Yes No If yes, a copy of your Exemption Letter from the IRS must accompany this report. If applied for and waiting for determination,
check here . If no, do not complete this form; instead, request Form UC-1A from this office.
6a. Non-profit organizations, determined to be liable, have the option of reimbursing the Connecticut Unemployment Compensation Fund for
unemployment compensation benefits paid former employees, or paying the regular State Unemployment Compensation Tax. Please indicate
Your option below.
Reimbursement of benefits paid method Regular quarterly tax method
7. Describe the function of the organization. BE SPECIFIC.
Health _________________________________________________________________________________________________________________
Educational _____________________________________________________________________________________________________________
Charitable ______________________________________________________________________________________________________________
Other __________________________________________________________________________________________________________________
8. Structure of organization Corporation Other (explain fully) _______________________________________________________________
9. Names of Officers or Directors Soc. Sec. Nos. Titles Home Addresses
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
10. When did you first engage employees in Connecticut under the present type of organization? ____________________________________________ Mo. Day Yr.
11. Did this organization succeed another? Yes No
If yes, list previous employer ______________________________________________________________________________________________
Was the previous employer subject to Conn. Unemployment Compensation Law? Yes No _______________________________________ Employer Number
Will the previous employer remain active? Yes No
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