Form 1g - School And Government Status Report - Department Of Workforce Services, State Of Utah
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1
2Utah Department of Workforce Services
DWS-U1
Form 1G
Unemployment Insurance
Rev. 5/01
140 East 300 South
P.O. Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400
FAX (801) 526-9377
SCHOOL AND GOVERNMENT
STATUS REPORT
INSTRUCTIONS ON REVERSE SIDE. PLEASE COMPLETE ALL ITEMS.
1. Type of Organization:
School District
City Government
County Government
State Government
Other, Specify __________________________
2. Name of School or Governmental Unit:
3. Name and SSN of Each Organization Officer:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. Address of School or Governmental Unit Headquarters
5. Mailing Address for Quarterly Contribution (tax) reports if
(No. Street, City, State, Zip Code):
different from item 4: (See Instructions)
Telephone #: (
)
Fax #: (
)
Telephone #: (
)
Fax #: (
)
6. Mailing address for Wage and Separation requests if different
7. Street address of Principal Permanent Work Site in Utah if
from item 5: (See Instructions)
different from item 5: (See Instructions)
Telephone #: (
)
Fax #: (
)
Telephone #: (
)
Fax #: (
)
8. Number of permanent worksites
9. County in Utah where
10. Date organization
11. Federal Employer I.D. Number (FEIN):
in Utah:
principal activity is
in item 2 began
located?
operation:
12. Describe your organization’s principal activity:
13. Elected method of reporting and payment: Important - this decision must be made by individual(s) with the authority to make a financial
commitment for the organization. (See Instructions)
a. Reimbursement of Unemployment Benefits Paid
The above organization elects to reimburse the Unemployment Insurance Fund an amount equal to the amount of regular benefits and of one-
half of the extended benefits paid that is attributable to service performed by former employees of the above organization. This election
requires the filing of quarterly employment and wage reports.
b. Payment of Quarterly Contributions
The above organization elects to file quarterly reports and pay any contributions as required by Section 35A-4-302 of the Utah Employment
Security Act. The following information is needed to determine the tax rate.
14. Enter below the amount of wages you have paid in Utah. If you have not paid wages enter “NONE”.
Jan. 1 to Mar. 31
Apr. 1 to Jun. 30
Jul. 1 to Sep. 30
Oct. 1 to Dec. 31
Current
Year:
Preceding
Year:
15. If you have not paid wages, do you expect to pay wages in the future?
Yes
No Estimated date ___________________________
I certify that I have authority to act as agent for the above organization. The information contained in this report is true and correct.
(
)
Authorized Agent
Title
Telephone
Date
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