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REGISTRATION FOR UNEMPLOYMENT INSURANCE TAX Job Service Use
JOB SERVICE NORTH DAKOTA EAN
UNEMPLOYMENT INSURANCE ST
SFN 41216 (R. 10-2022)
RE
BY FR
RA YR -1
UI TAX AND FIELD SERVICES
PO BOX 5507 -2 Q NAIC
BISMARCK NORTH DAKOTA 58506- 5507 LOC OWN
701-328-2814 FAX: 701-328-1882 TTY RELAY ND 800-366-6888

1. Business Name 3. Telephone Number

2. Corporate or Legal Name 4. Federal Employer ID (FEIN)

5. Mailing Address City State ZIP Code Website

6. Physical Address City State ZIP Code E-mail Address

7. Is (Are) any other business(es) being operated in North Dakota by this ownership? If yes, amen of usiness(es) b :
Yes No

8. Type of Ownership:
Individual Partnership (Indicate type: general, LP, LLP, etc.)
Corporation Click Limited Liability Company (LLC) (Indicate treatment for federal income tax reporting):
Nonprofit Corporation Disregarded Entity Partnership Corporation S-Corp Don't Know
Government Indian Tribe or Wholly-Owned Entity of an Indian Tribe
S-Corp Cooperative
Trust

In what state was your business originally incorporated/registered? Date :
9. List the owner(s) and all partners or corporate officers. Also, any corporate director or employee having a 20 percent or more ownership
interest. Attach separate sheet if necessary.
Social Security Percent
Name Address Title Number Owne d Exempt

* In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or
North Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax,
program eligibility purposes and program performance accountability.
10. Do you have employees working in North Dakota? If yes, date you first employed workers or corporate officers performed services:
Yes No

If you are a government entity, Indian tribe, or wholly-owned entity of an Indian tribe, go to Question 17.
11. Did you acquire any part of the ND assets or business of another employer or change your business status/structure in any way?
Yes No If yes, complete Schedule B.
12. Are you liable for federal unemployment taxes (FUTA)?
Yes No Don't Know If yes, go to Question 18. You will be covered under North Dakota law as of the first day you
employ workers in this state.

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SFN 41216 (1-2020)
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13. Are you a nonprofit organization exempt from income taxes under Section 501(c)(3), IRS Code?
Yes No - Go to #14 Applied For - Go to #14
If yes, complete this section and submit a copy of your exemption letter from the IRS to Job Service North Dakota. You need not
complete sections 14 and 15.
As a nonprofit organization, have you employed four or more persons during 20 weeks of any calendar year in any state?
Yes No -Go to #16 If yes, date the 20th week was first reache d:

When answering Questions 14 and 15, include as employees all part-time workers and non-exempt (see Employer's Guide) corporate
officers and limited liability company managers. Do not include spouse, children under 18 who live at home, or parents of an individual owner
- this does not apply to corporations or limited liability companies. This exclusion applies to partnerships only if the worker has an exempting
relationship with each partner.
14. Enter the amount of wages you have paid in North Dakota (do not estimate or include wages earned but not paid):
Jan. 1 to March 31 April 1 to June 30 July 1 to Sept. 30 Oct. 1 to Dec. 31
Current
Year $ $ $ $
Preceding
Year $ $ $ $
Prior
Year $ $ $ $

Year $ $ $ $

15. During the 20 weeks of any calendar year, have you employed: If yes, date the 20th week was first reached.
a. One or more persons in general employment? Yes No

b. Ten or more persons in agricultural employment? Yes No

16. If it is determined that you are not now liable for coverage, do you want to become covered voluntarily? Yes No
See NDCC 52-05-03(2) for voluntary coverage information.
Voluntary coverage is not available if you answered no to question #10
17. Complete this section only if you are a governmental entity, Indian tribe or wholly-owned entity of an Indian tribe, or a 501(c)(3) tax
exempt organization and answered yes to either Question 13 or 16.
Select one of the following benefit financing options: (see NDCC 52-04-18 for benefit financing methods)
Reimbursement of benefit payments attributable to employment with your organization.
Payment of taxes on your quarterly taxable payroll at the rate applicable for new employers.
Advanced reimbursements at a percent of your quarterly total payroll to be redetermined annually.
Will default to Payment of Taxes: 1) if not completed and/or 2) if you have not provided an IRS exemption letter.
18. Have any individuals you do not consider employees performed services for you in North Dakota? Yes No
If yes, give reasons for excluding them and indicate number of persons involved:

19. Does any part of your business activity include the provision of "temporary" or "leased" workers to a client company? Yes No

20. Give a specific description of your business activity in North Dakota.

Enter on separate lines the principal product or activities of your firm. Following each item, list the percentage of sales value or receipts
received from the product or activity; i.e., retail men's clothing, electrical construction-residential, or long haul trucking-refrigerated van.

% %

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SFN 41216 (1-2020) 
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21. Business Locations: Enter the North Dakota addresses from which your employees work and indicate if the location is permanent or
    temporary. If you do not maintain an office in North Dakota, enter the employee's address.
                   Address               City State ZIP Code                                      Telephone              Permanent Temporary 

Remarks: 

22. 
Name of Authorized Representative  Title            Telephone Number                                                Email Address

Name of Individual Completing Form Title            Telephone Number                                                Date 

    I certify the information on this Registration for Unemployment Insurance, Tax is true and accurate. 

                                   Job Service is an equal opportunity employer/program provider. 
                           Auxiliary aids and services are available upon request to individuals with disabilities.

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REPORT TO DETERMINE LIABILITY Complete Schedule B only if you answered “yes” to question 11 on
SCHEDULE B - SUCCESSORSHIP QUESTIONNAIRE form SFN 41216, Report to Determine Liability
Successorship Reporting Requirement. If you acquired all or part of the organization, business, trade, or assets of another employer and will continue
essentially the same business activity, you must provide the following information. If you made multiple acquisitions, you must file a separate Schedule B for
each acquisition. Submit the completed Schedule B(s) along with Form SFN 41216, Report to Determine Liability, to Job Service North Dakota.
PART 1: CURRENT/NEW OWNER INFORMATION
Name

UI Account Number Federal Employer Identification Number

PART 2: FORMER OWNER INFORMATION
Former Owner's Name (required) Former Owner's UI Number or FEIN, if known

Corporate Name or DBA Area Code and Telephone Number

Current Street Address (not a P.O. Box) City State ZIP Code

PART 3: ACQUISITION INFORMATION
Percent Acquired Date Acquired
1. Did you acquire all, part or none of the former owner's assets? All Part None
Percent Acquired Date Acquired
2. Did you acquire all, part or none of the former owner's workforce? All Part None
3. Did you acquire all, part or none of the former owner's North Percent Acquired Date Acquired
Dakota trade (customers/accounts)? All Part None
4. Did you acquire all, part or none of the former owner's North Percent Acquired Date Acquired
Dakota business (products/services)? All Part None
5. Was the North Dakota business being operated at the time of the Date (MM, DD, YYYY)
acquisition? If no, enter the date it was closed by the former owner. Yes No

6. Are you continuing the North Dakota business you acquired? Yes No
7. Is your North Dakota business substantially owned or controlled in
any way by the same interests that owned or controlled the former Yes No
business?
8. Will the previous business/account continue in business in North Yes No Don't Know
Dakota?
9. If eligible, do you wish to continue the experience rating established Yes No
by the acquired/previous business?
If you do and are assigned your predecessor's tax rate, your new account will also be chargeable for any benefits payable to your
predecessor's workers.
If you do not answer this question and it is determined that you are a liable employer, you will receive the rate normally assigned to new employers; it will
not include the predecessor's history.

NDCC 52-04-08.2 provides for penalties in cases where the acquisition of a business is solely or primarily for the
purpose of obtaining a lower unemployment insurance tax rate. Criminal and/or civil penalties apply.

Name of Owner/Officer

Title Telephone Number Date

I certify the information on SFN 41216, Schedule B, is true and accurate.

Notice: Wage and other confidential information collected from employers as part of the unemployment insurance process may be
requested and utilized for other governmental purposes, including, but not limited to, verification of eligibility under other government
programs as required by law.

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