Department of                                 P.O.	Box	8007
                                              Little	Rock,	AR	72203-8007   STATUS                Report	To	Determine	Liability	Under	The	 	
                                              Telephone	(501)	682-3798                           Department	of	Workforce	Services	Law
WORKFORCE           SERVICES                                               REPORT
                                                     IDENTIFICATION SECTION
1.	ACCOUNT	NUMBER	ASSIGNED	BY	DWS	(IF	ANY)                                   2.	FEDERAL	EMPLOYER	I.D.	NUMBER

3.	TYPE	OF	OWNERSHIP	(CHECK	ONE)	 	 	 	   	 	                         1.	 o	Corporation	         1a.	o	LLC	            2.	   o	Partnership
3.	  o	Individual	(Sole	Proprietor)	  4.	 o	Professional	Association	 5.	 o	Limited	Partnership	 6.	 o	Estate	         7.	   o	State	Agency	
8.	  o	Political	Subdivision	         9.	 o	Trust	                    10.	o	Leasing	(PEO)
IF	THE	TYPE	OF	BUSINESS	IS	A	CORPORATION/LLC	ENTER	THE	CORPORATE	NAME	IN	ITEM	4	BELOW.
4.	NAME                                                                      5.	MAILING	ADDRESS

CITY                                                       STATE	             ZIP	CODE                 PHONE	NUMBER
                                                                                                       (	             )
6.	ENTER	THE	NAME	(OR	FIRM	NAME)	AND	BUSINESS	ADDRESS	WHERE	PAYROLL	RECORDS	ARE	KEPT	(IF	DIFFERENT	FROM	ITEM	#5).
NAME                                                                         MAILING	ADDRESS

CITY                                                       STATE	             ZIP	CODE                 PHONE	NUMBER
                                                                                                       (	             )
If	the	type	of	ownership	is	an	individual	or	partnership,	enter	the	name(s)	and	social	security	number(s)	as	applicable	below,	or	if	the	type	of	
ownership is a corporation/LLC, complete the information for two ofcers.  Do not list Board Members or Directors.	
7.	Owners	Or NAME                                  SOCIAL	SECURITY	NUMBER    TITLE          RESIDENCE	ADDRESS,	CITY,	STATE,	ZIP
Corporate
   Ofcers
   Attach	
Additional
Sheet	If
Necessary
8.	Business  TRADE	NAME                                    STREET	ADDRESS,	CITY,	ZIP,	COUNTY                           TELEPHONE	NO. No.	of	Employees
PHYSICAL
LOCATION
In	Arkansas
REQUIRED
   Attach
	Additional
Sheet	If
Necessary
9.  IF YOUR BUSINESS          ORIGINAL	CORPORATE	NAME,	IF	DIFFERENT	THAN	ABOVE
    IS A CORPORATION/▲ ▲
    LLC, ENTER:
10.                           PREVIOUS	OWNER’S	ACCOUNT	NUMBER	 (IF	KNOWN)                                      ▲   ▲   MONTH   DAY   YEAR
    IF THE BUSINESS                                                                DATE	OF	ACQUISITION:
    IN ARKANSAS 
    WAS ACQUIRED              NAME	OF	PREVIOUS	OWNER                          ADDRESS                                  CITY          STATE
    FROM ANOTHER 
    LEGAL ENTITY▲ ▲           WHAT	PORTION	OF	THIS
                                                      (CHECK	(ONE)	
    ENTER:                    ACCOUNT	WAS	ACQUIRED?		                     ❒	 ALL.	 ❒	    PART(SPECIFY	PERCENTAGE)	_____________________
                                                      EMPLOYMENT SECTION
11.                                                                                                            ▲   ▲   MONTH   DAY   YEAR
   ENTER	THE	DATE	YOU	BECAME	LIABLE	FOR	STATE	UNEMPLOYMENT	(HAD	ONE	OR	MORE	EMPLOYEES	
   IN	SOME	PART	OF	TEN	DAYS)	(ACA	11-10-209)(1).	 SEE	INSTRUCTIONS
                                                                                                               ▲   ▲
11a. ENTER	THE	DATE	YOU	FIRST	PAID	WAGES	IN	ARKANSAS
12. IF	YOUR	ACCOUNT	HAS                 ENTER	THE	DATE	YOUR	ORGANIZATION	RESUMED	EMPLOYING                     ▲  ▲
          BEEN	INACTIVE:                SOMEONE	IN	ARKANSAS.
13. IF	YOU	ARE	EXEMPT	FROM	FEDERAL	INCOME	TAXES	UNDER	INTERNAL	REVENUE	CODE	OF	1954	SECTION	501	(C)(3),	ATTACH	
   A	COPY	OF	YOUR	EXEMPTION	LETTER.	               INDICATE	YOUR	PREFERENCE:	            o	 REIMBURSE	      	    o	 CONTRIBUTORY	
                                        DOMESTIC - HOUSEHOLD EMPLOYMENT SECTION
             Complete 14 only if	you	have	domestic	or	household	employees(Includes	maids,	cooks,	chauffeurs,	sitters,	etc.)
14.ENTER	THE	ENDING	DATE	OF	THE	FIRST	CALENDAR	QUARTER	IN	WHICH	YOU	PAID	GROSS	WAGES	▲                              ▲  MONTH   DAY   YEAR
    OF	$1,000	OR	MORE	TO	EMPLOYEES	PERFORMING	DOMESTIC	SERVICE:
                                                      REPORTING SECTION

   DWS	ENCOURAGES	ALL EMPLOYERS	TO	REGISTER	AND	FILE	ONLINE	AT:		www.ar-tax.org
DWS-ARK-201	(Rev.	01-07)	PAGE	1	OF	2	                                                                                  (CONTINUED	ON	REVERSE	SIDE)

                                                           AGRICULTURE EMPLOYMENT SECTION
15.
   ARE	YOU	AN	AGRICULTURAL	EMPLOYER?	(FARM	OR	RANCH)	 .....................................................................................	                                  o	 YES	 o	 NO
16.ENTER	THE	ENDING	DATE	OF	THE	TWENTIETH	WEEK	IN	WHICH	YOU	HAD	AT	LEAST	TEN	EMPLOY-▲                                                           ▲             MONTH           DAY          YEAR
   EES	IN	ARKANSAS	PERFORMING	AGRICULTURAL	LABOR:
17.ENTER	THE	ENDING	DATE	OF	THE	FIRST	CALENDAR	QUARTER	IN	WHICH	TOTAL	WAGES	OF	▲                                                                ▲
   $20,000.00	OR	MORE	WERE	PAID	FOR	AGRICULTURAL	LABOR:
                                                                 VOLUNTARY ELECTION SECTION
18.
   IF	YOU	ARE	NOT	LIABLE	UNDER	A	COMPULSORY	PROVISION	OF	THE	DEPARTMENT	OF	WORKFORCE	SERVICES	LAW,	AND	
   WISH	TO	VOLUNTARILY	ELECT	COVERAGE	FOR	YOUR	EMPLOYEES;	CHECK	HERE	 o,	AND	ENTER	THE	YEAR	YOU	WISH	LI-
   ABILITY	TO	BEGIN:		__________________________________
   		                                               AT	THE	END	OF	TWO	(2)	YEARS	FROM	THIS	DATE,	OR	AT	THE	END	OF	ANY	SUBSEQUENT	
   	                                                CALENDAR	YEAR,	YOU	MAY	WITHDRAW	THIS	ELECTION	BY	FILING	A	WRITTEN	REQUEST.
   	                                                YOU WILL BE NOTIFIED OF THIS DETERMINATION IN WRITING.
                                                                 NATURE OF BUSINESS SECTION
19.
   DESCRIBE	FULLY	THE	NATURE	OF	YOUR	
   BUSINESS	IN	ARKANSAS	AND	LIST	THE	
   PRINCIPAL	PRODUCTS	IN	ORDER	OF	IM-▲                          ▲
   PORTANCE:
   CODE     SHORT TITLE                                          CODE      SHORT TITLE	                                               CODE      SHORT TITLE
   	 11   Agricultural, Forestry, and Hunting                    	 441	-	 Motor	Vechicle	and	Parts	Dealers                              533 -  Lessors of Nonnancial Intangible Assets
   	 111	 -	 Crops	Production                                    	 442	-	 Furniture	and	Home	Furnishings	Stores                       	 	  	 	 	 (except	Copyrighted	Works)
   	 112	-	 Animal	Production                                    	 443	-	 Electronic	and	Appliance	Stores                             	 54  Professional, Scientic, and Technical Services
   	 113	-	 Forestry	and	Logging                                 	 444	-	 Building	Material	and	Garden	Equipment	and	Supplies	Dealers   541 -  Professional, Scientic, and Technical Services
   	 114	-	 Fish,	Hunting,	and	Trapping                          	 445	-	 Food	and	Beverage	Stores                                    	 55  Management of Companies and Enterprises
   	 115	-	 Support	Services	for	Agriculture	and	Forestry        	 446	-	 Health	and	Personal	Care	Stores                             	 551	-	 Management	of	Companies	and	Enterprises
   	 21		 Mining                                                 	 447	-	 Gasoline	Stations                                           	 56  Administrative and Support and Waste Management
   	 211	-	 Oil	and	Gas	Extraction                               	 448	-	 Clothing	and	Clothing	Accessories	Stores                             and Remediation Services
   	 212	-	 Mining	(except	Oil	and	Gas)                          	 451	-	 Sporting	Goods,	Hobby,	Book,	and	Music	Stores               	 561	-	 Administrative	Support	Services
   	 22   Utilities                                              	 452	-	 General	Merchandise	Stores                                  	 562	-	 Waste	Management	and	Remediation	Services
     221	-	 Utilities                                            	 453	-	 Miscellaneous	Store	Retailers                               	 61  Educational Services
   	 23   Construction                                           	 454	-	 Nonstore	Retailers                                          	 611	-	 Educational	Services
   	 236	-	 Construction	of	Buildings                            	 48-49   Transportation and Warehousing                             	 62  Health Care and Social Assistance
   	 237	-	 Heavy	and	Civil	Engineering	Construction             	 481	-	 Air	Transportation                                          	 621	-	 Ambulatory	Health	Care	Services
   	 238	-	 Specialty	Trade	Contractors                          	 482	-	 Rail	Transportation                                         	 622	-	 Hospitals
   	 31-33  Manufacturing                                        	 483	-	 Water	Transportation                                        	 623	-	 Nursing	and	Residential	Care	Facilities
   	 311	-	 Food	Manufacturing                                   	 484	-	 Truck	Transportation                                        	 624	-	 Social	Assistance
   	 312	-	 Beverage	and	Tobacco	Product	Manufacturing           	 485	-	 Transit	and	Ground	Passenger	Transportation                 	 71  Arts, Entertainment, and Recreation
   	 313	-	 Textile	Mills                                        	 486	-	 Pipeline	Transportation                                     	 711	-	 Performing	Arts,	Spectator	Sports,	and	Related	Industries
   	 314	-	 Textile	Product	Mills                                	 487	-	 Scenic	and	Sightseeing	Transportation                       	 712	-	 Museums,	Historical	Sites,	and	Similar	Institutions
   	 315	-	 Apparel	Manufacturing                                	 488	-	 Support	Activities	for	Transportation                       	 713	-	 Amusement,	Gambling,	and	Recreational	Industries
   	 316	-	 Leather	and	Allied	Product	Manufacturing             	 491	-	 Postal	Service                                              	 72  Accommodation and Food Services
   	 321	-	 Wood	Product	Manufacturing                           	 492	-	 Couriers	and	Messengers                                     	 721	-	 Accommodation
   	 322	-	 Paper	Manufacturing                                  	 493	-	 Warehousing	and	Storage                                     	 722	-	 Food	Services	and	Drinking	Places
   	 323	-	 Printing	and	Related	Support	Activities              	 51 Information                                                     	 81  Other Services (except Public Administration)
   	 324	-	 Petroleum	and	Coal	Products	Manufacturing            	 511	-	 Publishing	Industries	(except	internet)                     	 811	-	 Repair	and	Maintenance
   	 325	-	 Chemical	Manufacturing                               	 512	-	 Motion	Picture	and	Sound	Recording	Industries               	 812	-	 Personal	and	Laundry	Services
   	 326	-	 Plastics	and	Rubber	Products	Manufacturing           	 515	-	 Broadcasting	(except	internet)                              	 813	-	 Religious,	Grantmaking,	Civic,	Professional,	and	Similar
   	 327	-	 Nonmetallic	Mineral	Product	Manufacturing            	 516	-	 Internet	Publishing	and	Broadcasting                        	 	  	 	 	 Organizations
   	 331	-	 Primary	Metal	Manufacturing                          	 517	-	 Telecommunications                                          	 814	-	 Private	Household
   	 332	-	 Fabricated	Metal	Product	Manufacturing               	 518	-	 Internet	Service	Providers,	Web	Search	Portals,	and	Data    	 92  Public Administration
   	 333	-	 Machinery	Manufacturing                              	 	  	 	 	 Processing	Services                                       	 921	-	 Executive,	Legislative,	and	Other	General	Government	Support
   	 334	-	 Computer	and	Electronic	Product	Manufacturing        	 519	-	 Other	Information	Services                                  	 922	-	 Justice,	Public	Order,	and	Safety	Activities
   	 335	-	 Electrical	Equipment,	Appliance,	and	Component       	 52 Finance and Insurance                                           	 923	-	 Administration	of	Human	Resource	Programs
   	 	 	 	 	 Manufacturing                                       	 521	-	 Monetary	Authorities	-	Central	Bank                         	 924	-	 Administration	of	Environmental	Quality	Programs
   	 336	-	 Transportation	Equipment	Manufacturing               	 522	-	 Credit	Intermediation	and	Related	Activities                	 925	-	 Administration	of	Housing	Programs,	Urban	Planning
   	 337	-	 Furniture	and	Related	Product	Manufacturing	         	 523	-	 Securities,	Commodity	Contracts,	and	Other	Financial        	 	  	 	 	 and	Community	Development
   	 339	-	 Miscellaneous	Manufacturing                          	 	  	 	 	 Investments	and	Related	Activities                        	 926	-	 Administration	of	Economic	Programs
   	 42   Wholesale Trade                                        	 524	-	 Insurance	Carriers	and	Related	Activities                   	 927	-	 Space	Research	and	Technology
   	 423	-	 Merchant	Wholesalers,	Durable	Goods                  	 525	-	 Funds,	Trusts,	and	Other	Financial	Vehicles                 	 928	-	 National	Security	and	International	Affairs
   	 424	-	 Merchant	Wholesalers,	Nondurable	Goods               	 53 Real Estate and Rental and Leasing
   	 425	-	 Wholesale	Electronic	Markets	and	Agents	and	Broker	  	 531	-	 Real	Estate
   	 44-45  Retail Trade                                         	 532	-	 Rental	and	Leasing	Services
AGENCY                NAICS	CODE:             BLS	OWN	CODE:                AUX	CODE:                            COUNTY	CODES:             SEASON	CODE
    USE                                                                                                  	 STATUS	      BLS                                     Type	Reimbursable	_____
   ONLY                                                                                                                                                         Origination	Code	_______	
                                                                           SIGNATURE SECTION
20.
   I	HEREBY	CERTIFY	THAT	THE	PRECEDING	INFORMATION	IS	TRUE	AND	CORRECT,	AND	THAT	I	AM	AUTHORIZED	TO	EXECUTE	
   THIS	STATUS	REPORT	ON	BEHALF	OF	THE	EMPLOYING	UNIT	NAMED	HEREIN.
   (AUTHORIZED SIGNATURES: OWNER, OFFICER, PARTNER OR AUTHORIZED AGENT PER POWER OF ATTORNEY. IF APPLI-
   CABLE, PLEASE ATTACH COPY OF POWER OF ATTORNEY.)
     SIGNED	BY:                                                                                   TITLE:

     CONTACT	E-MAIL	ADDRESS:                                       FAX	NO.:                                         TELEPHONE:                                DATE:

DWS-ARK-201	(Rev.	01-07)	 PAGE	2	OF	2