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THIS REPORT IS REQUIRED OF EVERY EMPLOYING UNIT AND WILL BE USED TO DETERMINE LIABILITY UNDER
THE NORTH CAROLINA EMPLOYMENT SECURITY LAW, GENERAL STATUTE 96 AND DIVISION REGULATIONS.
Employer Status Report For Agency Use Only: Account No. Liable A/C/AS
Y N
Please Read Instructions! Root OW/OF S Add ET AL S/PR BR Liab Date

NC Dept. of Commerce Del After Law Sec M/W County ERA Own
Division of Employment Security
Post Office Box 26504 Curr P1 P2 P3 P4 P5 Next

Raleigh, N.C. 27611-6504 Orig Ind Ctr React Date L Let St Adj TA

Please Type or Print in Black Ink PC Let
or File Online www.ncesc.com
Return Within 10 Days

1. Federal ID number:__________________ 2. N.C. Dept. of Revenue withholding ID number:

3. Enter any previously assigned North Carolina unemployment tax numbers:
4. Employer name:
Enter exact name of legal entity – for further details see instructions)
5. Trade name:

6. Mailing address:
Street or P.O. Box City State Zip Code
7. Phone number: (_______)_____________________________ 8. FAX number: (_______)

9. Contact person: ________________________________________________ Title

Phone number: ( ______ )________________________ E-mail Address:

10. N.C. business location: Number of Employees expected
Street (Do not use a post office box ) in the next 12 months:
N.C.
City Zip Code County
(Attach a list of ALL NC locations, if there is no NC business location, enter the primary employee’s home address)

11. Check type of ownership: Individual Sub-Chapter S Corporation LLC taxed as Individual
General Partnership 501(c)(3) - Attach a copy LLC taxed as Partnership
Corporation Governmental LLC taxed as Corporation
Limited Partnership - Attach a list of ALL General Indian Tribal Governments/Enterprises
Partners Disregarded Entity
Other:
12. Enter the principal activity or services performed in your North Carolina operation:

13. If you are part of a larger organization and are primarily engaged in providing support services to that organization,
check one of the following:
Control, Administrative (Headquarters, etc.) Storage/Warehouse
Research, Development or Testing Other

14. Enter date you first employed one or more workers in North Carolina: _________/________/___________
MM DD YYYY
For Items 15 through 20, check only the ONE item that applies
15. GENERAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $1,500 or more? Yes No _____/_______/_______
If yes, enter the date this occurred or will occur. MM DD YYYY
b. Have you or will you employ at least one worker in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No ______/_______/______ ____/_______/_______
MM DD YYYY
16. Are you an EMPLOYEE LEASING company? Yes No
17. AGRICULTURAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $20,000 or more?
If yes, enter the date this occurred or will occur Yes No _____/_______/_______
MM DD YYYY
b. Have you or will you employ at least 10 workers in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No _____/_______/_______
MM DD YYYY

NCUI 604 (Rev 01/2012) OVER PLEASE

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18. DOMESTIC EMPLOYERS:
Have you or will you pay $1,000 or more in a calendar quarter for domestic
service in a private home, college club, fraternity or sorority? If yes, enter the Yes No ______ /______/ _______
date this occurred or will occur. MM DD YYYY

19. NON-PROFIT ORGANIZATIONS: (Attach a copy of Federal Letter of Exemption under Section 501(c)(3) of the Internal
Revenue Code.)
Have you or will you employ four or more workers in 20 different calendar weeks
during a calendar year? If yes, enter the date this occurred or will occur. Yes No ______ /______/ _______
MM DD YYYY
20. GOVERNMENTAL ENTITY: (check one type below)
Federal State Local Other: ________________________________________

21. If you are not otherwise subject to the unemployment tax law under one of the preceding criteria (Items 15-
20), do you wish to voluntarily cover your employees for unemployment insurance? Yes No
22. Have you ever paid Federal Unemployment Tax (FUTA)? Yes No
If yes, for what year(s)? ________ ________ ________ ________ ________

23. If you have acquired, transferred assets or merged with another business, or made any other changes in the ownership of the
business, including changes, such as from a sole proprietorship to a corporation or a partnership, complete the following:

a. Name of Former Owner: _____________________________________________________________________________
(Full Organizational Name, including Trade Name)

b. Former Owner’s N.C. UI Tax Number: _______________________________________

c. Former Owner’s Address: ________________________________________ __________________ __ __ __________
Street or P.O. Box City State Zip Code
d. On what date did you acquire or change the business? ______ /______/ _______
MM DD YYYY
e. Did you acquire all or a portion of the former owner’s North Carolina business? All Portion (Specify) %______
f. Was the business in operation at the time you acquired it? Yes No Date Closed ______ /______/ _______
MM DD YYYY
g. Was the business in bankruptcy at the time you acquired it? Yes No

h. Does the former owner continue to have employees in North Carolina? Yes No

24. Do you have workers who perform services for your business whom you consider to be self-employed or
independent contractors? If yes, see instructions for list to be attached. Yes No
25. List owners (parent corporation, sole proprietor, ALL general partners, principal corporate officers, or members.) Attach a list of
those for which there is no space below.

______________________ ______________________ _______________________ ____________ _____________________
First Name Middle Name Last Name Title SSN or FEIN

_________________________________________ _______________________ __ __ ___________ (____) ____ ______
Street or P.O. Box City State Zip Code Phone

______________________ ______________________ _______________________ ____________ _____________________
First Name Middle Name Last Name Title SSN or FEIN

_________________________________________ _______________________ __ __ __________ (____) ____ ______
Street or P.O. Box City State Zip Code Phone

______________________ ______________________ _______________________ ____________ _____________________
First Name Middle Name Last Name Title SSN or FEIN

_________________________________________ _______________________ __ __ __________ (____) ____ ______
Street or P.O. Box City State Zip Code Phone

Be Sure That All Applicable Items Are Completed Before Signing
I certify that the information entered on this form is true and accurate, and that I am authorized by the named employing unit to
complete this report for determining unemployment tax liability.
_____________________________________________ ___________________________________ ______ /______/ ________
Signature Title MM DD YYYY

NCUI 604 (Rev 02/2012)

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