Mail To:                                                                                                                                                                                                           This form can be completed online at 
 Cashier - Texas Workforce Commission                                                                                                                                                                                www.texasworkforce.org   
 P.O. Box 149037                                                                                                                                                                                            
 Austin, TX 78714-9037 
  
                                                                                       Status Report 
                                                                                  Farm and Ranch Employment 
                                                         
                                                                                       Identification Section 
  1.    Account number assigned by TWC (if any)                    2.        Federal Employer ID Number                                                                         3.  Type of ownership (check one) 
                                                                                                                                                                                 
  4.    Name                                                                                                                                                                       corporation/pa/pc                          limited partnership 
                                                                                                                                                                                   partnership                                 estate 
  5.    Mailing address                                                                                                                                                            individual (sole proprietor/domestic)       trust 
                                                                                                                                                                                   limited liability company                   other (specify)                                                                                
  6.    City                                                           7.     County              8.  State                                                                      8(a).  Zip code               9     Phone number 
                                                                                                                                                                                                               (        )             
  10.   Business address where              Address                                                                                                                                                            Phone number 
        payroll records are kept:                                                                                                                                                                              (        )             
        (if different from above)           City                                                                                                                                                               State                  Zip 
                                                                                                                                                                                                                                                 
  11.   Owner(s) or officer(s)                                                                           
                       Name                                       Social Security No.   Title                                                                                                             Residence address, city, state, zip 
                                                                                                                   
  12.   Business locations in Texas                                                                                                                                                                                                                
               Trade name                                                     Street address, city, zip                                                                                                     Kind of business                       No. of employees 
                                                                                                                                                                                                                                                             
  13.   If your business is a corporation, enter: 
  Filing number            State incorporated                     Date incorporated    Registered agent's name 
                                                                                                  
  Registered agent’s address                                                           Original corporate name, if name has changed 
                                                                                                  
                                                                              Farm & Ranch Employment Section 
  14.   Enter the date you first employed someone to perform farm and ranch labor in Texas. (do not use future date):                                                                                                                            Mo                                                              Day    Year 
                                                                                                                                                                                                                                                                                                                             
  15.   Enter the date you first paid wages to someone performing farm and ranch labor in Texas.   (do not use future date):                                                                                                                                                                                             
                                                                                                                                                                                                                                                                                                                             
  16.   Enter the Saturday date of the 20 thweek that three or more individuals were employed in Texas performing farm or ranch labor. (All weeks 
        should be in the same calendar year. Count a week if anyone performed any service for any portion of any day.  The services do not have to 
        be performed on the same day of the week, in consecutive weeks or by the same employee.  If you do not reach 20 weeks of employment                                                                                                                                                                                  
        in the first calendar year of operation, begin again with the second calendar year and count until you reach 20 weeks in that year.)   Do not 
        use future dates 
  17.   Enter the ending date of the first quarter during the calendar year in which you paid total gross wages of $6,250 or more for farm and 
                                                                                                                                                                                                                                                                                                                             
        ranch labor. (Include wages of seasonal, migrant and any other farm and ranch labor.) 
  18.   Enter the date you first employed migrant workers in Texas.                                                                                                                                                                                                                                                          
  19.  Enter the date you first employed seasonal workers in Texas to perform work on a truck farm, orchard or vineyard. 
                                                                                                                                                                                                                                                                                                                             
  20.   Are you a crew leader?                Yes                                                                                                If “Yes”, do you hold a valid      Yes                     If “No”, do substantially all of the                                                                     Yes 
                                                                       certificate of registration under                                                                                                    members of the crew operate 
        (check one)                            No                                                                                                the farm labor contractor act?   No                                                                                                equipment which you provide?     No 
                                                                       (check one)                                                                                                                          (check one) 
  21.   Enter the year(s) your organization was liable for taxes under the Federal Unemployment Tax Act.                                                                                                                                                                                                                                          
            (begin with the most recent year.)                                                                                                                                                              (year)          (year)           (year)            (year) 
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                                                                                                Farm & Ranch Employment Section - Continued 
  22.    If your account has been inactive:                                                                                                                                                                                              Mo.  Day  Year 
                                                                                    A. Enter the date you resumed employing someone on a farm or ranch in Texas.                                                                                        
                                                                                         
                                                                                    B. Enter the date you resumed paying wages to someone performing farm or ranch labor in Texas.                                                                      
  23.    If the business in Texas was acquired from another legal entity, you must complete items 23-25.   If a partial acquisition, the predecessor/ successor may jointly submit 
           an application for partial transfer of experience. 
   
                        a) Previous owner’s TWC account number (if known)                    
   
                        b) Date of acquisition            
              
                        c) Name of previous owner(s)             
              
                        d) Address             
              
                        e) City                                                     State                                    
              
   What portion of business was acquired?  (check one)                                           all               part (specify)                      
   
  24.   On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to any 
           of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or 
           equitable interest in the successor business?   
   
                                                              Yes                           No  
   
  If “Yes”, check all that apply:                             same owner, officer, partner, or shareholder                                    sole proprietor incorporating 
   
                                                              same parent company                                                               other  (describe below) 
                                                                                                                                                                                                                                                                
   If “No,” on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to any of 
           these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor business? 
   
                                                              Yes                           No 
  25.   After the acquisition, did the predecessor continue to: 
           • Own or manage the organization that conducts the organization, trade or business? 
           • Own or manage the assets necessary to conduct the organization, trade or business? 
           • Control through security or lease arrangement the assets necessary to conduct the organization, trade or business? 
           • Direct the internal affairs or conduct of the organization, trade or business?  
                                                              Yes                           No 
  If “yes” to any of above, describe:   
                                                                                                                                                                                                                                                         
                                                                                         __________________________________________________________________________________________________ 
                                                                                                                  Nature of Activity Section 
  26.   Describe fully the nature of activity in Texas and list the principal products or services in order of importance. 
            ____________________________________________________________________________________________________________________________________  
           
            ____________________________________________________________________________________________________________________________________           
                                                                                                                  Voluntary Election Section 
  27.   A non-liable employer may elect to pay State Unemployment Tax voluntarily.  If an employer elects to do so, the employer is obliged to pay taxes for a minimum of two 
           calendar years, beginning with January 1 of the first year of the election.  The employer may withdraw the election by written request, at the end of the 2-year 
           period, if not yet liable under the Texas unemployment compensation act.  To elect this option, complete the following: 
   
               Yes, effective Jan. 1,          I wish to cover all employees (except those performing service(s) which are specifically exempt in the Texas Unemployment 
             Compensation Act). 
                                                                                                                  Signature Section             
  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. 
  (This report must be signed by the owner, officer, partner  orindividual with a valid written authorization on file with the Texas Workforce Commission) 
  Date of signature: 
   
  Month         Day         Year                                  Sign here                                                                                                                                            Title            
   
  Driver's license number                                                                              State                                                                                       E-mail address                 

Individuals may receive, review, and correct information that TWC collectsth                                      about the individual by emailing to open.records@twc.state.tx.us or writing to TWC Open Records, 
                                                                                                101 East 15  St., Rm. 266, Austin, TX 78778-0001. 
  
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