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 
                                                                                        
                  This report is required of every employing unit, and will be used to determine liability under the Texas Unemployment Compensation Act.  
                                     If you have employment in Texas on a farm or ranch, please complete Form c-1fr, available online. 
                                                                            Identification Section 
1. Account Number assigned by TWC (if any)     2. Federal Employer ID Number              3. Type of ownership (check one) 
                                                                                           
                                                                                                                                                                                                    4
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 records or payrolls are kept: (if different from above)  
 
      Address                                                                                      City                                 State                       Zip                                         Phone Number  (      )              
11.  Owner(s) or officer(s) [attach additional sheet if necessary] 
          Name                                 Social Security No.          Title                          Residence Address, City, State, Zip 
                                                                                                                      
12.  Business locations in Texas [attach additional sheet if necessary] 
         Trade name                       Street Address, City, Zip                                                       Kind of business                                                                                 No. of employees 
                                                                                                                                                                                                                                      
13.  If your business is a chartered legal entity, enter: 
         Charter number              State of Charter           Date of Charter         Registered agent's name 
                                                                                                   
         Registered agent's address                       Original legal entity name, if name has changed 
                                                                     
                                                                            Employment section 
14.   Enter the date you first had employment in Texas (do not use future date):                                                                                                              Month               Day       Year 
                                                                                                                                                                                                                                 
15.   Enter the date you first paid wages to an employee in Texas (do not use future date):                                                                                                                                  
                                                                                                                                                                                                                                 
16.  If your account has been inactive:                                                                                                                                                                                      
                                                                            Enter the date you resumed employment  in Texas:                                                                                                     
                                                                                                                                                                                                                             
                                                                            Enter the date you resumed paying wages in Texas:                                                                                                    
                                                                                                                                                                                                                             
17.   Enter the ending date of the first quarter you paid gross wages of $1,500.00 or more:                                                                                                                                      
18.   Enter the Saturday date of the 20 thweek that individuals were employed in Texas.                                                                                                                                      
      (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 
19.   If you hold an exemption from Federal Income Taxes underth   Internal Revenue Code Section 501(c)(3), attach a copy of your                                                                                            
      Exemption Letter. Also, enter the ending date of the 20   week of the calendar year in which 4 or more persons were                                                                                                        
      employed in Texas:  
20.   Enter the year(s) your organization was liable for taxes under the Federal Unemployment Tax Act:                    
      (begin with most recent year)                                                                                                                                                                                                  
                                                                                                                                                    (year)           (year)           (year)         (year) 
 21.  Does this employer employ any U.S. citizens outside of the U.S.?                  Yes                     No  
 
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                                                              Domestic - Household Employment Section 
                                    Complete 22 only if you have domestic or household employees (includes maids, cooks, chauffeurs, gardeners, etc.) 
22.   Enter the ending date of the first calendar quarter in which you paid gross wages of $1,000 or more to employees                                  Month Day                                              Year 
      performing domestic service:                                                                                                                                                                                  
                                                                         Nature of Activity Section 
23.   Describe fully the nature of activity in Texas, and list the principal products or services in order of importance: 
                _________________________________________________________________________________________________________________________________ 
       
                _________________________________________________________________________________________________________________________________ 

24.   If the business in Texas was acquired from another legal entity, you must complete items 24-26. If a partial acquisition occurred, the predecessor/successor may jointly 
      submit information regarding a 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             __________________________            Zip             _________________________________ 
 
What portion of business was acquired?  (check one)              all                              part (specify)                                      
25.   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  
26.   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:            _____________________________________________________________________________________________  

                                                                         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 E. 15  St., Rm. 266, Austin, TX  78778-0001. 
                                                                                                                                                       
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