ABC         Over 6         Lag Date                                 UC-1A (Rev. 12/19)
Registration                                                            IC         Under 6     ___________              EMPLOYER STATUS REPORT 
Number: ______________________                                                                                            For UNEMPLOYMENT 
                                                                        666                         148                     COMPENSATION 
________________________For Office Use Only                             151                         713 
Status ___________________________________ 
Rate(s)___________________________________                              Other ______________________ 
Quarter(s)_________________________________                             Predecessor Reg. No.: 
Date Rec’d                                                              ___________________________          

REGISTRATIONS SHOULD BE COMPLETED ON-LINE AT WWW.CT.GOV/DOLTAX .   *501(C)(3) NON-PROFIT                                 EMPLOYER STATUS UNIT 
ORGANIZATIONS SHOULD REQUEST FORM UC-1NP.  THE STATE OF CONNECTICUT OR ITS MUNICIPALITIES                                200 FOLLY BROOK BLVD. 
SHOULD REQUEST FORM UC-1MUN.                                                                                            WETHERSFIELD,  CT  06109-1114 
                                                                                                                    TEL. NO.  (860) 263-6550    FAX   (860) 263-6567 

1. Federal Identification Number ___________________Tel.            No  .(     )_______________Fax 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 all Connecticut business locations, if different from above.  If mailing address is P.O. Box, please give the physical location of business.  Attach a
     separate sheet if necessary.  If only a salesman in Connecticut, please indicate salesman’s                                                                     home address.
     ___________________________________________________________________________________________________________
6a.  Describe the exact nature of the business.  If construction, state the type.  If manufacturing, list the principal products sold and their percent of the 
      total.  If trade, state whether retail or wholesaler and list the type of products sold.  If employer of HOUSEHOLD help, so indicate. 
     _________________________________________________________________________________________________________ 
6b.  State function of the Connecticut facility (i.e., headquarters, research facilities, etc.)___________________________________________________ 
7a.  Under what type of business organization do you operate?  (Check one of the following) 
          Individual / Sole Proprietorship        Partnership         Corporation       Other__________________________________________________ 
         LIMITED LIABILITY COMPANIES:            LLC – Sole Proprietor               LLC - Partnership     LLC – Corporation 
7b.  Corporations or LLC’s complete this item: 
      State in which Incorporated/Organized: _________________________________  Date of Incorporation/Organization:____________________________ 
                                                                                                                                  MM / DD / YY 
8.    List proprietor, partners, corporation officers, or members of a L.L.C. (Attach a separate sheet if necessary):
          Name                                    SS #                  Title                           Home Address – including Zip Code (Not a P.O. Box)  
     _________________________  _______________  _________________   _____________________________________________ 
     _________________________  _______________  _________________   _____________________________________________ 
     _________________________  _______________  _________________   _____________________________________________ 
9. When did you first engage employees working in Connecticut under your present type of organization? _____________________________________
     Note:   Officers of a corporation are considered employees for unemployment purposes.                                        MM / DD / YY 

10. Did you acquire ALL or PART of the employees, or assets, or organization, or trade and business in Connecticut of some other employer? 
    Note:  Acquisition can be facilitated by a third party such as a bank.         Yes         No      If Yes, All   Part
    If only part, describe what part was acquired:__________________________________________  Date Acquired _________________________
    What part was not acquired?_______________________________________________________                                            MM / DD / YY
     Is your business owned by the same interests as the predecessor?              Yes         No
11. If the answer to Item 10 is “Yes”, complete the following:
      1. Previous Employer’s Trade Name ________________________________________________________________________________________
      2. Name and address of previous proprietor, partner,
          or corporation officer___________________________________________________________________________________________________
      3. Was the previous employer subject to Connecticut Unemployment Compensation Law?                         Yes     No 
          Previous registration number_____________________________________________ 
      4. Will the previous employer remain in business in Connecticut?                    Yes            No 
12. Were you previously or are you now registered as an employer with the Connecticut Labor Department?
      Yes        No  If “Yes”, indicate registration number__________________________________________________________________________ 

You are liable for the CT and Federal Unemployment Tax if (a) during any calendar quarter of the current or preceding year you paid 
wages totaling $1,500 or more, or (b) you had, during the current or preceding calendar year, one or more employees at any time in 
each of 20 calendar weeks.  

13. When you first hired employee(s) in Connecticut, did you already meet FUTA liability?   YES          NO        NOT SURE 
14. As of the date of this application, have you met the liability requirements for this current calendar year? YES   NO     NOT SURE
    If NO, please complete 15 and 16:           Week-ending date when 20 thweek of employment met:__________________ 
15. If you have engaged employees and anticipate meeting the liability requirements in this calendar year you will be
    subject as of the first date you engaged employees.  However, a Connecticut registration number can not be issued until
    you actually meet the liability requirements, unless you voluntarily accept coverage.  Do you wish to accept coverage at
    this time? YES     NO
16. If you have engaged employees and do NOT meet the liability requirements in this calendar year, but anticipate meeting
    the liability requirements next year, you will be subject commencing January 1.   However, a Connecticut registration
    number can not be issued until you actually meet the liability requirements, unless you voluntarily accept coverage
    commencing January 1.  Do you wish to accept coverage?  YES                   NO
17. List below the gross wages paid to individuals in your employ in Connecticut.  Include FULL and PART-TIME employees and
    OFFICERS, if a corporation.  See UC-1A Instructions for the definition of gross wages.
                                     1  stQuarter                  2 ndQuarter        3 rdQuarter               4 thQuarter 
                                  (Jan. 1 – Mar 31)                (Apr. 1 – June 30) (July 1 – Sept. 30) (Oct. 1 – Dec. 31) 
Current Year ____________        $______________      $______________                 $______________     $_____________ 
Prior Year 1 ____________        $______________      $______________                 $______________     $_____________ 
Prior Year 2 ____________        $______________      $______________                 $______________     $_____________ 

Note:  For Domestic (Household)      and Agricultural please check box and list only cash wages above 

18. AGRICULTURAL EMPLOYERS – Did you employ 10 or more agricultural workers (excluding aliens admitted to the United States
    pursuant to Sections 214 (c) and 101 (a)(15)(H) of the Immigration and Nationality Act) for some portion of a day during any 20
    calendar weeks, not necessarily consecutive, in either the preceding or current calendar year?
    YES         NO     If  “Yes”,th                                                                                                  list the week-ending date when the 20  week of employment was (or will be) met _______________

    Did or will you pay cash wages of $20,000, or more in any calendar quarter of the preceding or current calendar year?
    YES       NO

19. DOMESTIC EMPLOYERS: Did or will you pay cash wages of $1,000, or more in any calendar quarter in either the preceding or
    current year? YES          NO
20. Do you have individuals performing services that you believe to be excluded from coverage or whom you believe to be
    independent contractors?      YES        NO
    If  “Yes” explain below.  (Attach separate sheet if necessary).
    ____________________________________________________________________________________________________

    _____________________________________________________________________________________________________
21. Bank Name: ___________________________________________________________________________________________
    Address and Account Number:_____________________________________________________________________________
22. Name of accountant and/or payroll service, if any: _____________________________________________________________

    Address and Telephone Number: __________________________________________________________________________
23. Please enter the total number of employees paid wages in Connecticut during the pay period which includes the 12 thday of
    each month in the first quarter you reported employment?  1st Mo.  _________   2 ndMo.  __________  3 rdMo. ___________

THIS FORM MUST BE SIGNED BY THE OWNER, A PARTNER, CORPORATE OFFICER, OR AN AUTHORIZED EMPLOYEE. 
             ALL OTHERS MUST PROVIDE DOCUMENTATION OF AUTHORIZATION (I.E., POWER OF ATTORNEY). 

I certify that the information in this report is true and correct. 
By_____________________________________________                      Prepared By________________________________________ 
                      (Signature)                                                           (Signature) 
Print Name _____________________________________                     Print Name __________________________________________ 
Title ____________________________________________                   Address ____________________________________________ 
Date ___________________________________________                     Title ________________ Tel. Number __________________