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KANSAS DEPARTMENT OF LABOR Page 1 of 5
www.dol.ks.gov
For Internal Use Only SUBMIT ONLINE: www.KansasEmployer.gov
EMPLOYER STATUS REPORT MAIL: Unemployment Tax Contributions
K-CNS 010 (Rev. 3-19) P.O. Box 400
Topeka, KS 66601-0400
FAX: (785) 291-3425

See instructions on page 5. The information requested in this report is required to be provided by K.S.A. 44-714(f) and K.A.R.
50-2-5. It will be used only by public officials in the performance of their public duties. Section 6103(d) of the Internal Revenue
Code authorizes IRS to exchange information with us for audits and certifications.

1. What is your type of organization / ownership? (check one below)
Individual Limited Partnership Estate
General Partnership Joint Venture Receivership
Limited Liability Company (LLC) Corporation (Inc.) Trust
Limited Liability Partnership (LLP) Governmental/Political Sub-Division (if checked, answer questions 2a and 2b)
Other: ________________________________________________________________________________________
2. If you are a governmental or political sub-division, select the branch of government and your finance option:
2a. Branch of government (check one) 2b. Finance option (check one)
State Local Indian Tribe Contributing Reimbursing Rated Governmental
3. Are you a 501(c)(3) exempt organization? YES NO (if YES, answer 3a and 3b)
3a. Finance option (check one) Contributing Reimbursing
3b. Have you received the 501(c)(3) exemption letter from the IRS? YES NO (if NO, explain below)

4. Are you a Professional Employment Organization (P.E.O.)?
YES (If YES, you must submit a separate K-CNS 015 for each client.) NO
5. Describe the major service, activity or product in Kansas that generates the most revenue for your business:
________________________________________________________________________________________________
5a. Is your business considered to be in the construction industry? YES NO
6. Date you first paid wages in Kansas: _________________________
7. List your Federal Employer Identification Number (FEIN): ______________________________
8. Legal business name (Inc., LLC, LP, Sole Prop, etc.): ___________________________________________________________
9. Business or trade name (if different than #8): ________________________________________________________________
10. Business phone: _______________________________________( ) Business fax: ________________________________( )
Business Email: ___________________________________________________________________________________
11. Mailing address - Street:______________________________________________________________________________
City: ______________________________________________________ State: ________ ZIP: ____________________
12. Kansas business physical address: Storefront/Physical Location Job/Construction Site Employee Residence
Street: ___________________________________________________________________________________________
City: ______________________________________________________ State: ________ ZIP: ____________________

UNEMPLOYMENT TAX CONTRIBUTIONS
P.O. Box 400, Topeka, KS 66601-0400 • Phone (785) 296-5027 • Fax (785) 291-3425

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Kansas Department of Labor                                                                                                 Page 2 of 5
Employer Status Report
K-CNS 010 (Rev. 3-19)

13. Address where accounting records are maintained/can be examined in the state of Kansas:                   Address same as #12
Street: ___________________________________________________________________________________________
City:  ______________________________________________________  State:  _______  ZIP:  ____________________

14. Company or in-house payroll contact:
Name:  ____________________________________________________________ Phone: ________________________(        )

Email: _____________________________________________________________________                                  Address same as #12
Street: ___________________________________________________________________________________________
City: ______________________________________________________  State: ________ ZIP:  ____________________

15. Ownership identification – Owner, Corporate Officer, Member, Member/Manager, Partner (general & limited), etc. Use
full LEGAL names. Do NOT use nicknames. Provide residence address of each owner, officer, partner, etc. Use page 4
if additional space is needed.

           Social Security number: ________________________ Title: __________________________________________ 
  First name: ____________________________  MI: _________ Last name:  ______________________________
  Street:    ____________________________________________________________________________________ 
City:  _______________________________________________________ State:  ___________ ZIP:  __________

 Social Security number:  ________________________ Title: __________________________________________ 
  First name: ____________________________  MI: _________ Last name:  ______________________________
  Street:  _____________________________________________________________________________________ 
 City:  _______________________________________________________ State:  ___________ ZIP:  __________

   Social Security number: ________________________ Title: __________________________________________ 
  First name: ____________________________  MI: _________ Last name:  ______________________________

  Street:   ____________________________________________________________________________________ 
 City:   ________________________________________________________ State:  __________ ZIP:   __________

16. Record all Kansas wages paid by calendar quarter for the current and prior calendar year.
           Year                  1st Quarter       2nd Quarter       3rd Quarter                    4th Quarter
                           $                 $                 $                             $
                           $                 $                 $                             $

17. In which WEEK did you establish liability based on the number of weeks of employment? ______________________

                                             UNEMPLOYMENT TAX CONTRIBUTIONS
                           P.O. Box 400, Topeka, KS 66601-0400 •  Phone (785) 296-5027  •  Fax (785) 291-3425

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Kansas Department of Labor Page 3 of 5
Employer Status Report
K-CNS 010 (Rev. 3-19)
18. Did you acquire/purchase all or part of an existing business? c YES NOc
18a. If YES, the date acquired (mm/dd/yyyy): ____________________ c All c Part ______ % acquired
Did you acquire substantially all of the assets? c YES cNO
Did you acquire substantially all of the employing enterprise, organization, trade or business? c YES cNO
Termination date of prior owner (mm/dd/yyyy): ____________________
18b. Has the previous owner continued business in Kansas? c YES cNO If YES, explain:
____________________________________________________________________________________________
18c. Do you want the prior owner’s experience rating factors? c YES cNO
Transfer of rating factors is: c Mandatory c Elective
18d. Name of prior owner: __________________________________
Prior owner’s Kansas employer serial number: _______________
18e. Prior business or trade name: _____________________________________ Current phone: ___________ ________
18f. Prior owner’s current address: Street ______________________________________________________________
City: _______________________________________________ State: _________ ZIP: ______________________
K.S.A. 44-710a(b)(2) allows a successor, defined in K.S.A. 44-703(h)(4) and K.S.A. 44-703(dd), the choice to acquire the experience rating factors of the
predecessor employer. The request for transfer must be made in writing within 120 days of the acquisition. The experience rating factors are all of the
unemployment taxes paid, annual payrolls and benefit charges of the predecessor employer. These factors are used to compute your unemployment tax rate
for subsequent years. Alternately, successor employers may elect to be assigned their industry tax rate.
K.S.A. 44-710a(b)( ) 1 shall be unlawful through manipulation of the employer's workforce, or business, to knowingly obtain a reduced liability for contributions
related to determining a contribution rate, when the primary purpose of the business acquisition was for the purpose of obtaining a lower rate of contributions,
or for a person to knowingly advise an employing unit in such a way that results in such a violation, shall be subject to penalties.
19. For the last three years, list any multiple business locations you have operated in KANSAS. c No multiple locations
Trade Name and Address Date Opened Date Closed No. Employees Business Activity

20. Are you subject toFederal Unemployment Tax Act (FUTA)? Current year: c YES c NO Prior year: c YES c NO
21. If no liability is indicated, do you wish to elect coverage?
c YES, beginning January 1 of the current year, or at the commencement of employment of the current year, and
continuing for not less than two calendar years, on behalf of the employing unit, I voluntarily elect to: (select one or both)
c become an employer described in K.S.A. 44-703(h), the same as other employers, since no
mandatory coverage is indicated
c extend coverage to all workers performing services that are excluded from coverage by the employment
security law
c NO
22. Are you continuing to pay wages inKANSAS? c YES cNO
23. Do you have individuals performing services you believe are not employees? c YES cNO
If YES, explain. Attach additional pages if necessary.

24. Would you like to have a KDOL representative contact you to provide additional information on exemptions, payment
options for governmental/political sub-divisions or 501(C)(3) entities, successorship or any other status report information?
c YES cNO

25. I certify that the information I have provided on this report is complete, correct and true to the best of my knowledge and
belief.

Signature of owner, partner, member/manager, corporate officer, etc. Title Date
UNEMPLOYMENT TAX CONTRIBUTIONS
P.O. Box 400, Topeka, KS 66601-0400 • Phone (785) 296-5027 • Fax (785) 291-3425

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Kansas Department of Labor                                                                                        Page 4 of 5
Employer Status Report
K-CNS 010 (Rev. 3-19)

Space for additional information (include question number):

                           UNEMPLOYMENT TAX CONTRIBUTIONS
                           P.O. Box 400, Topeka, KS 66601-0400 •  Phone (785) 296-5027  •  Fax (785) 291-3425

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Kansas Department of Labor K-CNS 010 INSTRUCTIONS Page 5 of 5
Employer Status Report
K-CNS 010 (Rev. 3-19)
1. Place an X before the appropriate type of ownership of 15. Enter the legal names of officers, members, member/
your business. If not listed, place an X in OTHER and managers, partners or owners of the business. Include
describe the ownership. Social Security numbers for each listing and title of the
2a. Place an X before your type of governmental agency: person (Corp. Pres., Mem/Mgr, Mem. Gen Ptr, Owner, etc.).
State, local (city, county, etc.) or Indian Tribe. Enter your street number, the direction (N, S, NE, SW, etc.),
2b. Place an X in the selected finance (payment) option. the street name, any apartment or suite number, city, state
3. Indicate if you are a 501(c)(3) organization. If YES, you and ZIP.
must complete questions 3a and 3b. 16. Enter your Kansas wages, by calendar quarter, for the
a. Place an X in the finance option. current calendar year and the prior calendar year.
b. Place an X in the YES box if you have received 17. Enter a number from 1 through 52 which indicates the
your IRS exemption letter. If NO, explain. number of the week during the current or prior calendar
4. Indicate if you are a Professional Employment year in which you had sufficient employees for at least 20
Organization (Employee Lease Organization). If YES, weeks. For purposes of this report, each week counted
you must complete a K-CNS 015 for each client that you must include the Saturday. The weeks do not have to be
represent. consecutive. For general employment, you must have one
5. Describe your major service or product in Kansas (that or more employees each week; agriculture employment
portion producing the major income source). must have 10 or more employees each week; and 501(c)
a. Indicate if your business is considered to be in the (3) employment is four or more employees in each week.
construction industry. 18. Are you operating a business that was once operated
6. Enter the first date you paid wages in Kansas. by someone else? Note: If you reorganized/restructured
7. List your nine-digit Federal Employer Identification your business and are now reporting employees under
Number (FEIN) issued by the IRS used on your 940 and a different entity/FEIN, please answer YES to the above
941 reports. question.
8. Enter your legal business name (for example - ABC Inc., a. Enter the date when you purchased or acquired the
ABC, LLC, John Smith, Sole Proprietor, etc.). business and whether you purchased all the business or
9. Enter your business or trade name (doing business as what percent of the business. Enter termination date of
name, Dark Corner #1, ABC Inc. d/b/a House Restaurant, prior owner.
etc.). b. Is the prior owner operating any other business in
10. Enter your actual business phone number, including the Kansas? If YES, explain how the previous owner
area code. List the main fax number and business email. continues in operation.
11. Enter the business mailing address where c. Would you like to have the prior owner's unemployment
correspondence from the agency is to be sent. List your tax rate and experience factors used to calculate your
street number or PO Box, the direction (N, S, NE, SW, tax rate?
etc.), the street name, any apartment or suite number, city, d. Enter the name of the prior owner and serial number, if known.
state and ZIP. e. Enter the prior business or trade name and phone.
12. Indicate if your Kansas location is a storefront/physical f. Enter the prior owner's current address, if known.
location, a job/construction site or an employee's 19. List each business location you have operated in Kansas
residence. Tell us the Kansas location's street number, for the last three years. If you have more than one, list
direction of street address (N, S, NE, SW, etc.), the street each location separately.
name and apartment number or suite number, city, state 20. Indicate if you are subject to the Federal Unemployment
and ZIP. Tax Act (FUTA), for the current or prior year.
13. Enter the Kansas location where your accounting 21. Indicate if you wish to elect to extend unemployment
records are maintained and can be examined by agency insurance coverage to your workers if a determination
personnel. If the address information is the same indicates that you are not required by statute to cover
as entered in item #12, place an X in the checkbox. employees. You may also elect coverage for workers who
Otherwise, enter the street number, direction of street are not defined by the statute as employees. (Election of
address (N, S, NE, SW, etc.), the street name and coverage is for two calendar years). If YES, place an X
apartment number or suite number, city, state and ZIP. before your choice of coverage. If NO, place an X in the
14. Indicate who is your company or in-house payroll contact NO box.
person. If the address information is the same as entered 22. Indicate if your business is continuing to pay wages in
in item #12, place an X in the checkbox. Otherwise, enter Kansas.
the street number or PO Box, direction of street address 23. Indicate which workers you believe are not employees.
(N, S, NE, SW, etc.), the street name and apartment Explain in detail why you consider them to be something
number or suite number, city, state and ZIP. Also list the other than employees.
main company email address of the payroll contact person 24. Indicate if you would like a further explanation from a
and a direct phone number. KDOL staff member about any questions on this form.
25. Sign the report, providing your title and the date.

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