UC 201-B EMPLOYER’S INI TIAL STATEMENT
Rev. 5-08 WORKFORCE WEST VIRGINIA
UNEMPLOYMENT COMPENSATION DIVISION
Required by Article 10, Section 11 of the West Virginia Unemployment Compensation Law
3977640 160655 DO NOT WRITE IN THIS SECTION
Effective Date:
Liable Date:
Provision:
Decision By:
Date:
Fed ID No:
State ID No:
Rate:
Merit Year:
0 0 DO NOT WRITE IN THIS SECTION
Effective Date:
Liable Date:
Provision:
Decision By:
Date:
Fed ID No:
State ID No:
Rate:
Merit Year:
RETURN ORIGINAL WITHIN TEN DAYS
1. Name(s)
Telephone Number
DBA
Business Address and Zip Code
Mailing Address and Zip Code
E-mail Address
County
Federal Number
2. Physical location of business (be specific):
3. Name, street address, telephone number, and person to contact where payroll records are maintained:
4. (a) Check (X) form of organization:
Individual
Partnership
Domestic Only
Agricultural Only
LLC If you are an LLC, do you file with the IRS as a corporation? Yes
No
Corporation
State of Incorporation
Date of Incorporation
Governmental Entity, Political Subdivision or Instrumentality
Taxable
Reimbursable
Nonprofit organization exempt from income tax under IRS Code Section 501(C) (3) ONLY.
Attach copy of U.S. Treasury letter giving this exemption.
Taxable
Reimbursable
(b) List Name, Social Security Number and Resident Address of Proprietor; all Partners, LLC members or Officers of the Corporation.
Name and Title
Social Security Number (Required)
Resident Address (Required)
5. Nature of Business:
WV Location:
6. If you have been assigned an Employer Account Number by this Division, please enter the number here:
7. Date you began operation in West Virginia:
/ /
Date first wages paid in West Virginia:
/ /
Business/assets acquired from another employer?
Yes
No If Yes, enter date:
/ /
Give name, address and zip code of predecessor; also federal reporting and state U.I. numbers (if known)
Federal Number
State UI Number
8. Have you ever or do you expect to employ at least ONE worker in 20
different calendar weeks during a calendar year?
No
Yes Month
Year
If Yes, in what earliest month and year will the 20 th week occur?
9. Have you or do you expect to have a quarterly payroll of $1,500?
If Yes, in what earliest quarter and year will the payroll occur?
No
Yes Quarter
Year
10. Have you or do you expect to employ in any calendar year, 10 or
more agricultural workers in 20 different calendar weeks?
No
Yes Month
Year
If Yes, in what earliest month and year will the 20 th week occur?
11. Have you or do you expect to have a $20,000 quarterly payroll of
agricultural workers in any year?
No
Yes Quarter
Year
If Yes, in what earliest quarter and year will the payroll occur?
12. Have you or do you expect to have a $1,000 quarterly payroll of
domestic ( housekeepers, babysitters, etc) workers in any year?
No
Yes Quarter
Year
If Yes, in what earliest quarter and year will the payroll occur?
13. If you are a nonprofit organization with a 501 (c)(3) exemption, have
you or do you expect to employ four or more workers in 20
different calendar weeks during a calendar year?
No
Yes Month
Year
If Yes, in what earliest month and year will the 20 th week occur? P lease furnish a copy of exemption letter .
14. Are you liable for the Federal Unemployment Tax?
Yes
No If Yes, in what year did you become liable?
In what states?
15. State the number of Individuals working in West Virginia:
In other states:
16. Enter the greatest number of employees you had in any one day in the calendar week. Include part-time and extra workers as well as your regular employees. Partners of a partnership are not employees. An individual proprietor of a proprietorship is not an employee. OFFICER’S SALARIES ARE REPORTABLE. Wages of the members of a limited liability company are reportable if the LLC files with the IRS as a corporation but are not reportable if the LLC files with the IRS as a partnership. (Work performed in the employ of a son, daughter, or spouse, or work performed by a child under 18 in the employ of his mother or father, is excluded from the definition of employment.)
FOR CALENDAR YEAR ________
FOR CALENDAR YEAR ________
CALENDAR WEEKS
CALENDAR WEEKS
1ST
2ND
3RD
4TH
5TH
1ST
2ND
3RD
4TH
5TH
1ST
2ND
3RD
4TH
5TH
1ST
2ND
3RD
4TH
5TH
JAN
JUL
JAN
JUL
FEB
AUG
FEB
AUG
MAR
SEP
MAR
SEP
APR
OCT
APR
OCT
MAY
NOV
MAY
NOV
JUN
DEC
JUN
DEC
17. Show quarterly and yearly wages if one or more individuals are employed for any part of a day.
WEST VIRGINIA
PAYROLLS
CALENDAR QUARTER
ENDING MARCH 31
CALENDAR QUARTER
ENDING JUNE 30
CALENDAR QUARTER
ENDING SEPT. 30
CALDENDAR QUARTER
ENDING DEC 31
TOTAL FOR YEAR
PRECEDING YEAR
________
CURRENT YEAR
________
If you have not started business, check here
Give estimated start date
Sign on line 18.
18. CERTIFICATION: This report must be signed by owner if business is operated as an individual proprietorship; by an authorized partner
if business is operated as a partnership or joint venture; by an authorized member of an LLC; by an authorized officer of an incorporated
business. Signatures of any other party will not be accepted unless this form is accompanied by a valid power of attorney.
Date
Signature
Title
Date
Signature
Title
Date
Signature
Title
Date
Signature
Title
GENERAL INSTRUCTIONS
Item 1. Enter the name, business address, mailing address if different than the business address, telephone number and federal
employer identification number (FEIN) of your business. If you do not have a FEIN, contact the Internal Revenue Service
at 1-800-829-4933 or at www.irs.gov . Also, enter the West Virginia county where your business is located.
Item 2. Enter the physical location of business if different than your business and/or mailing address.
Item 3. Enter the name, address and telephone number of the individual you wish to be contacted concerning your payroll records.
Item 4(a). Choose your appropriate form of organization.
Item 4(b). Enter the name, title, social security number and resident address of the owner of a sole proprietorship, each partner of a
P artnership , each member of a LLC or each officer of a corporation.
Item 5. Enter the nature of your business and the city in West Virginia where your business is located.
Item 6. Enter your West Virginia Unemployment Compensation account number if one has been issued.
Item 7. Enter the date you began having employees in West Virginia and the date first wages were paid in West Virginia. Please
furnish the month, day and year. If you acquired any assets from another business, please furnish the date of acquisition
along with the name, address and account number of the predecessor.
Items 8-13 Enter the month, year and quarter for provisions applying to your business type.
Item 14. Enter the year you became liable for Federal Unemployment tax and in which state this occurred.
Item 15. Enter the number of individuals working in West Virginia and the number of individuals working in other states.
Item 16. Enter the number of employees by week. Include only employees working in West Virginia.
Item 17. Enter the amount of quarterly and yearly wages in the current and preceding year or the estimated start date if you have
not started your business.
Item 18. Affix only proper signatures in order for application to be processed.
Please return completed form by mail or fax: Status Determination Unit
P. O. Box 106
Charleston, West Virginia 25321
Fax number: 304-558-1324
Phone number: 304-558-2677
Document checksum: 1271090393
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