Form Dol-1n - Employer Status Report
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1
2GEORGIA DEPARTMENT OF LABOR
SUITE 850 - 148 ANDREW YOUNG INTERNATIONAL BLVD NE - ATLANTA, GA 30303-1751
EMPLOYER STATUS REPORT
READ INSTRUCTIONS BEFORE COMPLETION OF FORM
1. ENTER OR CORRECT BUSINESS NAME AND ADDRESS
RETURN ORIGINAL WITHIN 10 DAYS
GEORGIA DOL
ACCOUNT NUMBER
_
(If already assigned)
3. TRADE NAME
2. TYPE OF ORGANIZATION
Nonprofit org.
Individual
Corporation
Partnership
Street Address
4. PRINCIPAL BUSINESS,
FARM OR
Limited Liability CO. (LLC)
HOUSEHOLD
LOCATION IN
Other (specify)________________________
GEORGIA
City
Zip Code
County
Telephone Number
(Do not use a
GA
P. O. Box number)
(
)
5. DATE FIRST BEGAN
6. ARE YOU LIABLE
DATE OF
FEDERAL
EMPLOYING WORKERS
FOR FEDERAL
YES
NO
_
FIRST GA.
I. D.
WITHIN STATE OF GA.
UNEMPLOYMENT TAX?
PAYROLL
NUMBER
7. HAVE YOU..........
DATE ACQUIRED
DID YOU ACQUIRE..........
= =
=
OR CHANGED
All of Georgia operations?
Acquired another business?
Yes
No
= =
= = = = = = = = =
PREDECESSOR'S
GEORGIA DOL
_
Substantially all of Georgia operations
Merged with another business? Yes
No
ACCOUNT NUMBER
(90% or more)
= =
= =
=
DOES THE FORMER
Formed a corporation or
OWNER CONTINUE TO
Yes
No
Part of Georgia operations (less than 90%)
partnership?
Yes
No
HAVE EMPLOYEES?
= =
Made any other change in the
ownership of your business?
Yes
No
If yes, explain
FROM WHOM? (Organization name, including trade name)
ADDRESS
= =
= =
9. IF YOU HAD DOMESTIC EMPLOYMENT:
8. IF YOU HAD PRIVATE BUSINESS EMPLOYMENT:
Did you, or do you expect to pay cash wages
Did you, or do you expect to employ at least one worker Yes*
No
Yes*
No
of $1,000 or more in any calendar quarter?
in 20 different calendar weeks during a calendar year?
* If yes, show date this first occurred or will occur:
* If yes, show date the 20th week first occurred or will occur:
= =
= =
Yes*
No
10. IF YOU HAD AGRICULTURAL EMPLOYMENT:
Yes*
No
Did you, or do you expect to have a
Did you, or do you expect to employ 10 or more agricultural
quarterly payroll of $1,500 or more?
workers in 20 different calendar weeks during a calendar year?
* If yes, show date this first occurred or will occur:
* If yes, show date the 20th week first occurred or will occur:
= =
= =
11. IF YOU ARE A NONPROFIT ORGANIZATION EXEMPT
Did you, or do you expect to have a gross cash agricultural
Yes*
No
FROM INCOME TAX UNDER IRS CODE 501(c)(3):
payroll of $20,000 or more in any calendar quarter?
Yes*
No
Did you, or do you expect to employ four or more
* If yes, show date this first occurred or will occur:
workers in 20 different calendar weeks during a
calendar year?
12. HOW MANY EMPLOYEES do you have (or anticipate
c
(ATTACH COPY OF 501( )(3) EXEMPTION LETTER)
when in full operation)?
* If yes, show date the 20th week first occurred or will occur:
Name
INFORMATION
Name
INFORMATION
ABOUT
ABOUT
PERSON
OR FIRM
OWNER,
Social Security
Address
WHO
ALL
Number
_
_
MAINTAINS
PARTNERS,
FINANCIAL
OR PRINCIPAL
Residence Address
City
RECORDS
OFFICER
OF BUSINESS
(ATTACH
City
State
Zip Code
Telephone
ADDITIONAL
SHEET, OR
(
)
SHEETS, IF
State
Zip Code
CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those contained
NECESSARY)
in any attached sheets signed by me are true and correct, and that I am authorized to execute this report on
behalf of the employing unit. This report must be signed by owner, partner or principal officer.
Telephone
Signature
Title
Date
(
)
PLEASE COMPLETE INDUSTRY INFORMATION
DOL-1N (R-3/13)
TA489Y
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