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THIS REPORT IS REQUIRED OF EVERY EMPLOYING UNIT AND WILL BE USED TO DETERMINE LIABILITY UNDER
THE NORTH CAROLINA EMPLOYMENT SECURITY LAW, GENERAL STATUTE 96 AND DIVISION REGULATIONS.
Employer Status Report For Agency Use Only: Account No. Liable A/C/AS
Y N
Please Read Instructions! Root OW/OF S Add ET AL S/PR BR Liab Date

NC Dept. of Commerce Del After Law Sec M/W County ERA Own
Division of Employment Security
Post Office Box 26504 Curr P1 P2 P3 P4 P5 Next

Raleigh, N.C. 27611-6504 Orig Ind Ctr React Date L Let St Adj TA

Please Type or Print in Black Ink PC Let
or File Online des.nc.gov
Return Within 10 Days

1. Federal ID number:_ 2. N.C. Dept. of Revenue withholding ID number:
3. Enter any previously assigned North Carolina unemployment tax numbers:

4. Employer name:
Enter exact name of legal entity – for further details see instructions)
5. Trade name:
6. Mailing address: ___________________________________________ _ ___________________ ___ ____ _______
Street or P.O. Box City State Zip Code
7. Phone number: ( )_ - __ 8. FAX number: ( )__ -

9. Contact person: _______________________________________________ Title:
Phone number: ( )_ - _ _____________________ E-mail Address:

10. N.C. business location: Number of Employees expected
Street (Do not use a post office box) in the next 12 months:
N.C.
City Zip Code County
(Attach a list of ALL NC locations, if there is no NC business location, enter the primary employee’s home address)

11. Check type of ownership: Individual Sub-Chapter S Corporation LLC taxed as Individual
General Partnership 501(c)(3) - Attach a copy LLC taxed as Partnership
Corporation Governmental LLC taxed as Corporation
Limited Partnership - Attach a list of ALL General Indian Tribal Governments/Enterprises
Partners Disregarded Entity
Other:
12. Enter the principal activity or services performed in your North Carolina operation:

13. If you are part of a larger organization and are primarily engaged in providing support services to that organization,
check one of the following:
Control, Administrative (Headquarters, etc.) Storage/Warehouse
Research, Development or Testing Other

14. Enter date you first employed one or more workers in North Carolina: __ ___/__ ___/___ ________
MM DD YYYY
For Items 15 through 20, check only the ONE item that applies
15. GENERAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $1,500 or more? Yes No _ __/ _ __/__ __
If yes, enter the date this occurred or will occur. MM DD YYYY
b. Have you or will you employ at least one worker in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No __/ _ _/ _ __
MM DD YYYY
16. Are you an EMPLOYEE LEASING company? Yes No
17. AGRICULTURAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $20,000 or more?
If yes, enter the date this occurred or will occur Yes No _ _/ _ _ /__ __
MM DD YYYY
b. Have you or will you employ at least 10 workers in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No _ _/_ _/ _ ___
MM DD YYYY

NCUI 604 (Rev 01/2012) OVER PLEASE

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 18. DOMESTIC EMPLOYERS:
     Have you or will you pay $1,000 or more in a calendar quarter for domestic             
     service in a private home, college club, fraternity or sorority?  If yes, enter the             Yes      No     _  __ /__  _/        _   
     date this occurred or will occur.                                                                               MM          DD         YYYY 
 19. NON-PROFIT ORGANIZATIONS: (Attach a copy of Federal Letter of Exemption under Section 501(c)(3) of the Internal 
     Revenue Code.) 
     Have you or will you employ four or more workers in 20 different calendar weeks                                  
     during a calendar year?  If yes, enter the date this occurred or will occur.                    Yes      No     _  _ /__   /  _      _ 
                                                                                                                        MM          DD      YYYY 
 20. GOVERNMENTAL ENTITY:   (check one type below) 
       Federal                 State                 Local                   Other: __      ______________________________________ 
                                                                       
 21. If you are not otherwise subject to the unemployment tax law under one of the preceding criteria (Items 15-          
     20), do you wish to voluntarily cover your employees for unemployment insurance?                                       Yes             No 
 22. Have you ever paid Federal Unemployment Tax (FUTA)?                                                                    Yes            No 
     If yes, for what year(s)?         _     _            _     ____  __     ___         __     ___              __       
  
 23. If you have acquired, transferred assets or merged with another business, or made any other changes in the ownership of the 
     business, including changes, such as  from a sole proprietorship to a corporation or a partnership, complete the following: 
        
     a.  Name of Former Owner: _      ____________________________________________________________________________ 
                                                  (Full Organizational Name, including Trade Name) 
                                                                           
     b.  Former Owner’s N.C. UI Tax Number: __     _____________________________________ 
                                                                                                                                  
     c.  Former Owner’s Address: __________     ______________                           _________       _________       _    __ __       ____ 
                                                  Street or P.O. Box                                  City              State     Zip Code 
     d.  On what date did you acquire or change the business?         ___  ___ /__   __/ __    _____ 
                                                                         MM          DD        YYYY 
     e.  Did you acquire all or a portion of the former owner’s North Carolina business?                All        Portion (Specify) %_       
     f.  Was the business in operation at the time you acquired it?    Yes         No      Date Closed      __   _ /   _  _/ __    _____ 
                                                                                                               MM          DD        YYYY 
     g.  Was the business in bankruptcy at the time you acquired it?               Yes     No 
            
     h.  Does the former owner continue to have employees in North Carolina?                Yes       No 
            
 24. Do you have workers who perform services for your business whom you consider to be self-employed or                  
     independent contractors? If yes, see instructions for list to be attached.                                             Yes             No 
 25. List owners (parent corporation, sole proprietor, ALL general partners, principal corporate officers, or members.)  Attach a list of 
     those for which there is no space below. 
                                                                                                                       
 __       _____________        _      _____________________  __       _____________________         __       ________ _      _______________ 
      First Name                       Middle Name                        Last Name                         Title         SSN or FEIN 
                                                                                                                         
 ________________      _________________________   _________       ______________           _    __  __       _______   (     ) _    -          
               Street or P.O. Box                                    City                  State            Zip Code    Phone 
                                                                                                                       
 _______      ______________   ___       ________________    ___       ____________________         __       ________ ___       _____________ 
      First Name                       Middle Name                        Last Name                         Title         SSN or FEIN 
                                                                                                                         
 ______________________      ___________________   ____________       ___________         _      __  __       _____     (     ) _   _- _        
               Street or P.O. Box                                    City                  State            Zip Code    Phone 
                                                                                                                       
 ___________       __________  ___________       ___________ __       _____________________         _____       _____ ___       ___________ 
      First Name                       Middle Name                        Last Name                         Title         SSN or FEIN 
                                                                                                                         
 ____________________       _____________________  ___________       ____________         _      _   ____      ______   (     ) _    -       _ 
               Street or P.O. Box                                    City                  State            Zip Code             Phone 
                                                                      
                                Be Sure That All Applicable Items Are Completed Before Signing  
 I certify that the information entered on this form is true and accurate, and that I am authorized by the named employing unit to 
 complete this report for determining unemployment tax liability. 
 _____________________________________________               ___________________________________                     ______ /______/ ________ 
 Signature                                                   Title                                                       MM         DD         YYYY 
 
NCUI 604 (Rev 02/2012)

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