Status Report - Louisiana Department Of Labor
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1LOUISIANA DEPARTMENT OF LABOR
PHONE (225) 342-2944
U. I. Tax Liability and Adjudication
FAX
(225) 342-1943
STATUS REPORT
P. O. BOX 94186
BATON ROUGE, LA. 70804-9186
DO NOT WRITE IN THIS SPACE--FOR OFFICIAL USE ONLY
ACCOUNT OR REF NUMBER:
PLEASE REVIEW THE INSTRUCTIONS ON THE NEXT PAGE BEFORE COMPLETING THIS FORM.
1.
EMPLOYER or CORPORATION NAME
2. LA. WITHHOLDING NUMBER
3.
TRADE NAME or DBA NAME
4. FEDERAL EMP. I. D. NUMBER
5.
MAILING ADDRESS
P. O. BOX OR STREET
CITY
STATE
ZIP CODE
6. FAX NUMBER
7.
PHYSICAL LOCATION IN LOUISIANA
STREET
CITY
STATE
ZIP CODE
8. TEL. NO. (PHYSICAL LOCATION)
9.
NAME OF CONTACT PERSON WITH PAYROLL RECORDS
10. TEL. NO. (PAYROLL)
11.
NAME AND ACCOUNT NUMBER OF PREVIOUS OR EXISTING LOUISIANA ACCOUNTS
12 E-MAIL ADDRESS
13. TYPE OF ORGANIZATION:
Individual
Partnership
LLC
LLP
Corporation
State ________ Date ______________________
Other
Government : Local
State
Funding type:
General Approprications
Self Generated
Mixed Funds
14. Are you a Professional Employer Organization or do you have a contract with a PEO?
No
Yes
If "Yes", complete the information on the line below.
Name of PEO:
Fed ID:
Date of Contract:
15. LIST BELOW OWNER OF SOLE PROPRIETORSHIP, PARTNERS IN PARTNERSHIP, OR OFFICERS OF CORPORATION. (Attach separate sheet if necessary)
NAME AND TITLE
SOC. SEC. NO.
RESIDENCE
TELEPHONE
16. (A)
REGULAR EMPLOYERS:
Have you had or will you have total wages in a calendar quarter equal to or greater than $1500?
YES
NO
If "YES", enter the Quarter _______ and Year _______
OR
Have you had or will you have 1 or more employees for 20 weeks or more in a calendar year?
YES
NO
If "YES", enter the date of the 20th week with 1 or more employees.
Month _______
Day _______ Year _______
(B)
AGRICULTURAL EMPLOYERS:
If "YES", enter the date of the 20th week with 10 or more employees.
OR
Did you employ 10 or more agricultural workers in 20 weeks in a calendar year?
YES
NO
Month _______
Day _______ Year _______
OR
Did you have total wages in a calendar quarter equal to or greater than $20,000?
YES
NO
If "YES", enter the Quarter _______ and Year _______
(C ) DOMESTIC EMPLOYERS:
Domestic employers must elect to file Annually ___ or Quarterly ___
OR
Did you have total wages in a calendar quarter equal to or greater than $1000?
YES
NO
If "YES", enter the Quarter _______ and Year _______
(D)
NONPROFIT EMPLOYERS:
OR
Do have a 501(c )(3) exemption from the Internal Revenue Service?
YES
NO
If "YES", you must attach a copy of your letter of exemption from the IRS to be considered a NONPROFIT EMPLOYER, If "NO", you are are to answer 16(A).
Did you employ 4 or more workers for 20 weeks or more in a calendar year?
YES
NO
If "Yes", enter the date.
Month _______ Day _______
Year _______
17. LOCAL GOVERNMENT OR NON-PROFIT EMPLOYER: Indicate the method you elect to pay taxes: Taxable
Reimbursable
18.
DATE ENTITY FIRST HAD EMPLOYEE(S) IN LOUISIANA:
Month
Day
Year
18a.
# OF EMPLOYEES
19.
LOTTERY RETAILER/CONTROL #
20. ARE YOU LIABLE UNDER THE FEDERAL UNEMPLOYMENT TAX ACT (FUTA)
YES
NO
If "Yes", enter the date.
Month _______ Day _______
Year _______
21. DID YOU ACQUIRE ANY OF THE ORGANIZATION, TRADE, BUSINESS
A. IF YES, DID YOU ACQUIRE
B. IS THE BUSINESS ACQUIRED STILL OPERATING IN LOUISIANA?
*
OR ANY ASSETS OF ANOTHER LOUISIANA EMPLOYER?
PART
ALL
YES
NO
OF THE LOUISIANA OPERATION?
YES
NO
C. NAME OF ORGANIZATION ACQUIRED
D. THEIR LA. UNEMP.INS.NO.
E. DATE ACQUIRED
*
22. ADDITIONAL LOUISIANA ORGANIZATION ACQUIRED
A.
PART
ALL
THEIR LA. UNEMP.INS.NO.
DATE ACQUIRED
B. Still Operating: YES
NO
23. IF YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHO YOU CONSIDER TO BE INDEPENDENT CONTRACTORS, PLEASE READ #22 IN THE INSTRUCTIONS.
24.
DESCRIBE YOUR BUSINESS ACTIVITY. THIS INFORMATION WILL DETERMINE THE U.I. TAX RATE ASSIGNED TO YOUR BUSINESS. BE SPECIFIC!
List your main products or services in the space provided (i.e., full service restaurant, residential heating and air contractor, internet publisher).
Manufacturers, provide the type of product and materials used. If involved in more than one activity, provide approximate percentage of revenues or sales for each activity.
Attach a separate sheet if additional space is needed.
Please print the name and telephone number of the person who can supply additional information about your business activity.
Name
Telephone
Are the above services primarily performed for other locations of your company? ___YES ___NO
If employees work from their homes (i.e., sale representatives), please give the city, state and zip code.
City
State
ZIP Code
If your business is made up of more than one establishment in LOUISIANA, attach a separate sheet and list the physical location and employment count for each location.
PROFESSIONAL EMPLOYER ORGANIZATIONS - Provide a list of each of your clients, with EIN/UI number.
You will receive a quarterly Multiple Worksite Report to provide employment and
wage breakouts for each client. If the client has more than one location, you will be required to provide the employment and wage breakout for each location. This is a mandatory report.
* IN ORDER TO TRANSFER PART OF THE EXPERIENCE RATING RECORD OF THE PREDECESSOR, THE APPLICATION AND AGREEMENT FOR PARTIAL TRANSFER MUST BE SUBMITTED
WITHIN 180 DAYSOF ACQUISITION.
Signature and Title
Phone No.
Date
LDOL - ES 1 (REV. 01/2007)
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