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RETURN TO: TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER ACCOUNTS/EMPLOYER SERVICES TENNESSEE DEPARTMENT OF LABOR ANDWORKFORCE DEVELOPMENT
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE TN 37243-1002 REPORT TO DETERMINE STATUS
PHONE (615) 741-2486 FAX (615) 741-7214
EMAIL: employerstatus.rates@tn.gov APPLICATION FOR EMPLOYER NUMBER
1. Enter Federal Number, Business Name and Address OFFICIAL USE ONLY
Tennessee ID Number M. No. County Alt Zip
Federal Number -
Employer Name Liab. Org. First Employment Date Liable
Trade Name
Comp Year NAICS M-NAICS Verified
Mailing Address
Previous No. Rate
Physical Business Address in Tennessee (other than employee
residence) if different from above:
______________________________________________________
______________________________________________________ Phone:____________________ Fax:___________________
Business Website:_______________________________________ Email Address: ______________________________________
2. Have you previously had an account with this department? YES NO If YES, Account Number
3.Is your organization aProfessional Employer Organization(PEO)? YES NO If YES, Tennesseelicense number
Is your organization a client of aProfessional Employer Organization(PEO)? YES NO
If YES, STOP. STOP Please complete LB-0910, Application for Client Number.
NOTE:If corporation is a nonprofit, exempt from Federal Income Taxes under Section 501(C)(3) of the IRS Code, STOP. STOP
Please complete LB-0444, Report to Determine Status, Nonprofit Organization.
4. CHECK (X) FORM OF ORGANIZATION 5. Name of Owner, Partners, Corporate Officers, Limited Liability Company Social Security Number
Members and Managers (If Board Managed), General Partners
(Attach separate sheet if necessary.)
INDIVIDUAL _________________________________________________________________________
PARTNERSHIP _________________________________________________________________________
CORPORATION _________________________________________________________________________
LIMITED LIABILITY COMPANY _________________________________________________________________________
LIMITED PARTNERSHIP _________________________________________________________________________
OTHER _________________________________________________________________________
NOTE: If a Limited Liability Company, are you treated by IRS as a(n) Individual Proprietorship Partnership or as a Corporation?
6. Name of person responsible for payroll records Phone Number
7. A. Number of workers you have employed (will employ) in TN D. Are you presently reporting for U.I. purposes in another state?
YES NO If YES, which state?
B. Date you first employed (will employ) a worker in TN
E. If a corporation or LLC, provide formation information.
C.Date you first paid (will pay) a worker in Tennessee Date State Control No.
8. REGULAR BUSINESS EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you expect to employ at least one worker in twenty different calendar weeks during a calendar year? YES NO
If YES, give earliest month and year the twentieth week occurred (will occur). MONTH YEAR
B. Have you had or do you expect to have a quarterly payroll of $1,500 or more? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER YEAR
9. HOUSEHOLD EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER YEAR
10. AGRICULTURAL EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you expect to employ at least ten or more workers in some part of a day in twenty different weeks during a calendar year?
YES NO If YES, give earliest month and year this occurred (will occur). MONTH YEAR
B. Have you had or do you expect to have a quarterly payroll of $20,000 or more? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER YEAR
C. Is all activity performed on a farm? YES NO If NO, what percentage is? Please explain in 13A on page 2.
Must be signed by owner, partner, authorized limited liability company member or manager, or officer of the corporation.
Signature Title Date
PLEASE COMPLETE PAGE 2.
FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.
LB-0441 (Rev. 08-24) RDA 1559
