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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 | 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 |
| des. nc. gov | www. ncesc. com |
| Return Within 10 Days 1. Federal ID | Return Within 10 Days 1. Federal ID |
| number:_ | 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: | 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 | Street or P. O. Box City State Zip Code 7. Phone |
| number: ( ) _ - | number: ( _______) _____________________________ |
| __ | |
| 8. FAX | 8. FAX |
| number: ( ) __ | number: ( _______) |
| - | |
| 9. Contact person: | 9. Contact person: |
| _______________________________________________ Title: | ________________________________________________ Title |
| Phone | Phone |
| number: ( ) _ - | 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: | 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 | 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 | 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 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 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 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 | MM DD YYYY NCUI 604 ( Rev 01/2012) OVER PLEASE 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 | 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: | 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)? | 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: | 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: | Full Organizational Name, including Trade Name) b. Former Owner’s N. C. UI Tax Number: |
| __ | _______________________________________ |
| _____________________________________ | |
| c. Former Owner’s Address: | 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? | 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) | 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 | 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. | 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 | First Name Middle Name Last Name Title SSN or FEIN |
| ________________ _________________________ | _________________________________________ _______________________ |
| _________ ______________ _ | |
| __ __ | __ __ |
| _______ ( ) _ - | ___________ ( ____) ____ |
| | ______ |
| Street or P. O. Box City State Zip Code Phone | Street or P. O. Box City State Zip Code Phone |
| _______ ______________ ___ ________________ ___ | ______________________ ______________________ _______________________ ____________ _____________________ |
| ____________________ __ ________ ___ _____________ | |
| First Name Middle Name Last Name Title SSN or FEIN | First Name Middle Name Last Name Title SSN or FEIN |
| ______________________ ___________________ | _________________________________________ _______________________ |
| ____________ ___________ _ | |
| __ __ | __ __ |
| _____ ( ) _ _- _ | __________ ( ____) ____ ______ |
| Street or P. O. Box City State Zip Code Phone | Street or P. O. Box City State Zip Code Phone |
| ___________ __________ ___________ ___________ | ______________________ ______________________ _______________________ ____________ |
| __ | |
| _____________________ | _____________________ |
| _____ _____ ___ ___________ | |
| First Name Middle Name Last Name Title SSN or FEIN | 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) PDF file checksum: | 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) PDF file checksum: |
| 3751249934 | 810403542 |