![]() Enlarge image | BUSINESS REGISTRATION ATTN: EMPLOYER SERVICES TELEPHONE: 802-828-4344 VERMONT EMPLOYER NUMBER P.O. BOX 488 FAX: 802-828-4248 C-1 (12/21) MONTPELIER, VERMONT 05601-0488 COMPLETE BOTH PAGES OF THIS FORM, AND RETURN WITHIN 10 DAYS INCOMPLETE FORMS WILL OR GO TO 'EMPLOYER ONLINE SERVICES' AT WWW.LABOR.VERMONT.GOV. DELAY REGISTRATION. YOU WILL BE INFORMED OF YOUR VERMONT UI LIABILITY 1. FEDERAL ID NUMBER 2. EMPLOYER'S LEGAL NAME 5. MAILING ADDRESS STREET 3. TRADE OR DBA NAME (LIST ALL) CITY STATE ZIP CODE 4. ATTENTION OR C/O NAME 5A. E-MAIL ADDRESS/WEB ADDRESS 5B. TELEPHONE NUMBER 5C. FAX NUMBER 6. TYPE OF ORGANIZATION (CHECK ONE) SOLE-PROPRIETORSHIP OR DOMESTIC PARTNERSHIP CO-OWNER (Husband/Wife or Civil Union Partners) 501 (c)(3) CORPORATION, MUST ATTACH IRS EXEMPTION ASSOCIATION TRUSTEE IN BANKRUPTCY LIMITED LIABILITY COMPANY (LLC/LLP/L3C) CORPORATION, SPECIFY STATE AND DATE OF INCORPORATION ______________________________________________ 6A. LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS: NAME SOCIAL SECURITY NO. TITLE HOME ADDRESS (NO P.O. BOXES) MULTISTATE WORKERS 7. DO YOU HAVE EMPLOYEE(S) WHO WORKED FOR YOU IN ANOTHER STATE BEFORE WORKING IN VERMONT? NO YES 7A. FIRST DATE OF EMPLOYMENT IN VERMONT: ______________________ DATE FIRST WAGES PAID IN VERMONT: _______________________ 7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX ON WAGES PAID IN ANOTHER STATE IN PRIOR YEARS? NO YES, LIST YEARS ______________________________________________7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND THE TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED. IF EMPLOYMENT OCCURRED PRIOR TO THE CALENDAR YEARS LISTED BELOW, PLEASE ATTACH ADDITIONAL SHEETS WITH THE NEEDED INFORMATION. DO NOT ESTIMATE FUTURE WAGES. A WORKER IS ANYONE PERFORMING SERVICES FOR YOUR BUSINESS, UNLESS THEY ARE EXEMPT UNDER UNEMPLOYMENT. CALENDAR YEAR 2022 - ENTER NUMBER OF WORKERS IN EACH WEEK ENTER QUARTERLY GROSS WAGES PAID 1-Jan 8-Jan 15-Jan 22-Jan 29-Jan 5-Feb 12-Feb 19-Feb 26-Feb 5-Mar 12-Mar 19-Mar 26-Mar 2-Apr 9-Apr 16-Apr 23-Apr 30-Apr 7-May 14-May 21-May 28-May 4-Jun 11-Jun 18-Jun 25-Jun 2-Jul 9-Jul 16-Jul 23-Jul 30-Jul 6-Aug 13-Aug 20-Aug 27-Aug 3-Sep 10-Sep 17-Sep 24-Sep 1-Oct 8-Oct 15-Oct 22-Oct 29-Oct 5-Nov 12-Nov 19-Nov 26-Nov 3-Dec 10-Dec 17-Dec 24-Dec 31-Dec CALENDAR YEAR 2021 - ENTER NUMBER OF WORKERS IN EACH WEEK ENTER QUARTERLY GROSS WAGES PAID 2-Jan 9-Jan 16-Jan 23-Jan 30-Jan 6-Feb 13-Feb 20-Feb 27-Feb 6-Mar 13-Mar 20-Mar 27-Mar 3-Apr 10-Apr 17-Apr 24-Apr 1-May 8-May 15-May 22-May 29-May 5-Jun 12-Jun 19-Jun 26-Jun 3-Jul 10-Jul 17-Jul 24-Jul 30-Jul 7-Aug 14-Aug 21-Aug 28-Aug 4-Sep 11-Sep 18-Sep 25-Sep 2-Oct 9-Oct 16-Oct 23-Oct 30-Oct 6-Nov 13-Nov 20-Nov 27-Nov 4-Dec 11-Dec 18-Dec 25-Dec DEPARTMENT USE ONLY STATUS NAICS COUNTY TOWN LMI NAICS LIABLE NO YES REPORTS DUE NONE EXAMINED BY DATE LIABLE ESTAB IN UC MAIL TICKLE DATE LIAB CODE TYPE NEW ACS PREDECESSOR OR OLD NO. RATES RTA, SAME NO. PARTIAL ______________________________ RTA, NEW NO. FULL, TRANSFER EXPERIENCE CONTINUED ON PAGE 2 |
![]() Enlarge image | 8. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED - STREET (NOT RFD OR P.O. BOX #) TELEPHONE NUMBER CITY STATE ZIP CODE FAX NUMBER 9. DO YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHOM YOU CONSIDER TO BE SELF-EMPLOYED OR INDEPENDENT CONTRACTORS? YES NO IF YES, PLEASE ATTACH A LIST PROVIDING NAME, ADDRESS, TELEPHONE AND TYPE OF SERVICE PROVIDED/PERFORMED. 10. DID YOU ACQUIRE THE ORGANIZATION, TRADE, BUSINESS OR ANY ASSETS OF ANY OTHER VERMONT EMPLOYER? YES - Complete items 11A-11F and 12 NO, GO TO ITEM 12 DID YOU INCORPORATE YOUR VERMONT PROPRIETORSHIP OR PARTNERSHIP? YES - Account No.: __________________________ If YES, Complete items 11A-11F NO - Go to item 12 11A. DID YOU ACQUIRE ALL? PART? 11B. DATE ACQUIRED __________________ 11C. UNEMPLOYMENT ACCOUNT NUMBER OF BUSINESS ACQUIRED _________________ 11D. NAME OF BUSINESS ACQUIRED _________________________________________________________________________________________________________________ 11E. NUMBER OF EMPLOYEES RETAINED FROM FORMER OWNER NONE SOME ALL HOW MANY? ___________________________ 11F. HOW WAS BUSINESS ACQUIRED? (check one) PURCHASE MERGER FRANCHISE ENTITY CHANGE LEASE (SPECIFY NATURE OF THE LEASE) ____________________________________________________________________________________________ 12. HAVE YOU EVER HAD A VERMONT UNEMPLOYMENT ACCOUNT NUMBER FOR THIS BUSINESS OR ANY OTHER LEGAL BUSINESS ENTITY? YES NO IF YES, GIVE FULL BUSINESS NAME ________________________________________________________________________________________________ NATURE OF BUSINESS ACTIVITY 13A. PROVIDE A DETAILED DESCRIPTION OF THE NATURE OF ACTIVITY 13B. LIST PRINCIPLE PRODUCT(S) OR SERVICE(S), IN ORDER OF IN VERMONT. IMPORTANCE. 13C. PLEASE SELECT THE APPROPRIATE CATEGORY BELOW WHICH CLOSELY DESCRIBES YOUR BUSINESS IN VERMONT. IF YOU HAVE MULTIPLE BUSINESS TYPES, PLEASE SPECIFY THE PERCENTAGES IN 13A. ABOVE. PLEASE BE SURE TO PROVIDE DETAILS IN 13A AND 13B. Agriculture, Forestry, Fishing & Hunting Transportation & Warehousing Educational Services Mining Information Health Care & Social Assistance Utilities Finance & Insurance Arts, Entertainment & Recreation Construction Real Estate & Rental & Leasing Accommodation & Food Services Manufacturing Professional, Scientific & Technical Services Other Services (Except Administrative) Wholesale Trade Management of Companies & Enterprises Public Administration Retail Trade Administrative & Waste Services IF YOU ARE UNSURE OF THE CATEGORY IN WHICH YOUR BUSINESS FALLS, CONTACT LABOR MARKET INFORMATION AT (802) 828-3868 OR ACCESS THE WEB AT HTTP://WWW.NAICS.COM/SEARCH.HTM FOR MORE INFORMATION. 14. ENTER THE NUMBER OF ESTABLISHMENTS THE ABOVE BUSINESS OPERATES IN VERMONT If more than ONE location, attach a list specifying each INCLUDE: Home(s) of personnel, when the company does not have an office or worksite in Vermont. location with the STREET ADDRESS, CITY AND THE EXCLUDE: Locations that are temporary (exist less than 1 year) or are not staffed on a regular basis. NUMBER OF WORKERS AT EACH LOCATION. 15. The following information is necessary as future notices will be available electronically. If the general contact is also responsible for UI Tax and Benefit information, enter "Same" in those areas. UI General Contact* UI Tax Contact UI Benefit Contact INTERNAL contact if other contacts fail: Person/Service that completes UI Tax Returns Person/Service that completes separations/wage requests E-MAIL*:______________________________ E-MAIL:______________________________ E-MAIL:______________________________ * REQUIRED 16. SIGNATURE OF OWNER, PARTNER, OFFICER OF CORP., OR HEAD OF HOUSEHOLD TITLE DATE |