Department of
                                               INSTRUCTION SHEET 
WORKFORCE     SERVICES
                                               FOR PREPARATION OF THE STATUS REPORT
P.O. Box 8007 • Little Rock, AR 72203-8007     REPORT TO DETERMINE LIABILITY UNDER THE 
Telephone (501) 682-3798                       DEPARTMENT OF WORKFORCE SERVICES LAW

  ADWS ENCOURAGES ALL EMPLOYERS TO REGISTER AND FILE ONLINE AT:  www.ar-tax.org
                                           GENERAL INSTRUCTIONS

The Department of Workforce Services Law and Regulations provide that each employing unit paying wages 
for employment in Arkansas shall le a Report to Determine Liability on or before the last day of the 
month next following the month during which it became an employing unit.  That report is informational 
in nature and is used for the purpose of determining whether you are liable to pay the Arkansas State 
Unemployment Tax.

Liability is established under any of the following conditions: (1) Any employing unit having had in   
employment one (1) or more persons some portion of ten (10) or more days; (2) Any employing unit 
which acquires the organization, trade or business, or substantially all the assets thereof, of another   
already subject to the act; or by adding together the employment records of the predecessor and the suc-
cessor, the result of which would be employment in ten (10) or more days; (3) Any agricultural employing 
unit whose payroll equals $20,000 in a calendar quarter; or has 10 or more employees in 20 different 
weeks in a calendar year; (4) Any employing unit whose payroll equals $1,000 or more to individuals in 
domestic service in any calendar quarter in the calendar year or the preceding calendar year; (5) Any 
employing unit whose liability is not established by any of the foregoing provisions but who is liable under 
the Federal Unemployment Tax Act.

In order for this Agency to make a determination of your status, this report should be completed in ac-
cordance with the following instructions and must be led no later than the last day of the second month 
in which you became an employer/employing unit.

Type or print in ink.  If the space provided for any item is not sufcient for a complete answer, use ad-
ditional sheets and identify each answer by the corresponding item number in the report. 

Item 1   -    Enter the nine digit number if the employing unit shown in item 4 or 7 has or has 
              had an account with the Arkansas Department of Workforce Services (ADWS) within the last   
              three (3) years.

Item 2  -     Federal I.D. No. - The nine digit serial number assigned to you by the Federal Government.

Item 3  -     Check the type of ownership, whether individual, partnership, corporation, etc.

Item 4  -     Enter the corporate or legal name of employing unit.

Item 5  -     Specify the mailing address to be used by this Agency for all correspondence.

Item 6  -     Self-explanatory.

Item 7  -     Name of individual owner or names of partners.  Social Security numbers are  required of 
              all individuals and/or partners.

DWS-ARK-201A (Rev.1-07) PAGE 1 OF 2                                (CONTINUE ON REVERSE SIDE)

Item 8  -  Enter name by which the business is known to the public and the business address in 
           Arkansas.  The address shown should be the physical location in Arkansas from which the 
           services of your employees are directed or controlled.  If there is no physical location in   
           Arkansas, state the address from which direction/control is exercised.  Specify the county   
           the business (or job) is located in Arkansas and the average number of employees for this 
           business.  Enter a telephone number where you can usually be reached.

Item 9  -  Self-explanatory.

Item 10 -  If you acquired an on-going business, enter date the business was acquired and predeces- 
           sor’s name, address and ADWS Account Number (if known).  Enter the percent of the business 
           acquired.

If any individual, legal entity or other employing unit on or after January 1, 1972, acquires a segre-
  gable or identiable portion of the business of any employer and if such successor desires to obtain 
  any benet of his predecessor’s experience, such successor must le with the Director a petition, 
  signed by all interested parties within, thirty (30) days after the transfer, setting out the percentage 
  of the predecessor’s experience that each party is to receive.

Item 11 -  Enter the rst date of liability to the State of Arkansas - 11-10-209 (1).  Any individual or   
           employing unit which, for some portion of ten (10) or more days, whether the days are or   
           were consecutive, within the current or the preceding calendar year, has or had in employ- 
           ment one (1) or more individuals irrespective of whether the same individuals are or were   
           employed in each day.

Item 11a - Self-explanatory.

Item 12 -  Self-explanatory.

Item 13 -  Non-Prot Organizations   (as dened in the Federal Internal Revenue Code of Section 
           501(c)(3)) and any government employing unit may elect to reimburse the Unemploy- 
           ment Trust Fund under the provisions of Subsection 7(h).

Item 14 -  Enter information only if employing unit is domestic employment.

Item 15 -  Self-explanatory.

Item 16 -  Self-explanatory.

Item 17 -  Self-explanatory.

Item 18 -  If you are exempt under the law and you wish to elect coverage, indicate here and attach a 
           signed Form DWS-ARK-232 or your signed, written request.  The request must be   
           approved by the Director of the Arkansas Department of Workforce Services.  Upon approval 
           you must report wage information for two years before terminating your account.

Item 19 -  Enter the principal activity of the business.  Wholesale Trade, Retail Trade, Real Estate, 
           Insurance, Construction, Furniture Factory, Personal Service, etc.

Item 20 -  This report must be signed by an ofcial of this employing unit, either the owner, a   
           partner, or corporate ofcer (as applicable), or a legally authorized representative, per power 
           of attorney. If applicable, please attach copy of POW.  
DWS-ARK-201A (Rev. 1-07) PAGE 2 OF 2