State Form 52098 - Determination Of Professional Employer Organization (Peo) Status - Indiana Department Of Workforce Development
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1
2DETERMINATION OF PROFESSIONAL EMPLOYER ORGANIZATION (PEO) STATUS
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State Form 52098 (R3 / 10-13)
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
Toll Free: (800) 437-9136 Fax: (317) 233-2706
*
This agency is asking for your Social Security number, this record cannot be processed without it., CONFIDENTIAL RECORD PURSUANT TO IC 22-4-19-6, IC 4-1
PLEASE PRINT IN BLACK OR BLUE INK.
Federal Identification number:____ ____ - ____ ____ ____ ____ ____ ____ ____ SUTA account number:___________________
Legal name of business as registered with Secretary of State: _____________________________________________________
Trade name (or d/b/a): _________________________________________________________________________
Street address: ________________________________________________________________________________
City: _________________________________ State:________________________ ZIP code:_________________
Business telephone number: (
)
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Business fax number: (
)
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Enter the required information for owner, partners or officers. Please attach additional sheet(s) if needed.
Name (please print)
Title
Social Security Number*
Telephone Number
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-
(
)
-
-
-
(
)
-
-
-
(
)
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Formation Date of
State of
Date Payroll
Corporation or
Corporation:
Began in Indiana:
Partnership:
__ __
(mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
(mm/dd/yyyy)
List physical address maintained in Indiana.
1.
Is the registrant recognized as a Professional Employer Organization with the Indiana Department of
Yes
No
Insurance? Please attach a copy of the registration letter issued by the Department of Insurance.
2.
Does the registrant have individuals that are receiving remuneration for services that are
Yes
No
direct employees of the Professional Employer Organization in the State of Indiana?
Please check the reporting method that the Professional Employer Organization would like to use. Please
Client level
3.
note that a Professional Employer Organization must use the same reporting method for all of its clients
or
pursuant to IC 22-4-6.5-8(d).
PEO level
4.
Is the registrant currently reporting wages under a client's state unemployment tax account? Please
attach a list containing the state unemployment tax account numbers, federal identification numbers and
Yes
No
name of each employing unit operating in the State of Indiana.
5.
Please provide any state unemployment account numbers that were previously assigned to the registrant or a commonly owned,
managed or controlled entity. Attach additional pages for more account numbers if neccesary.
Account number
Account number
Account number
How many clients have entered into a co-employment relationship with the registrant in Indiana?
6.
7.
Does the registrant share any ownership interests with any of its client companies?
Yes
No
Does the registrant have any common officers with any its client companies?
Yes
No
8.
List all individuals or entities that direct or indirectly own any of the equity interest of the registrant.
9.
Individuals or Entities
Percentage of Ownership
Directly
%
Indirectly
%
Directly
%
Indirectly
%
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