Form Ldol-Es 1- Status Report printable pdf download

PHONE (225) 342–2944

LOUISIANA DEPARTMENT OF LABOR

FAX (225) 342-1943

OFFICE OF REGULATORY SERVICES

P. O. BOX 94186-

EMPLOYER STATUS UNIT

BATON ROUGE, LA 70804-9186

STATUS REPORT

DO NOT WRITE IN THIS SPACE - FOR OFFICIAL USE ONLY

ACCOUNT NO.

LIABILITY DATE

QUALIFYING DATE

LIABILITY CODE

PARTIAL CODE

TYPE CONT.-CODE

DETERMINED BY

DATE WORKED

STATUS REPORT CODE

ALL QUESTIONS ON BOTH PAGES OF THIS FORM MUST BE ANSWERED STARTING WITH NO. 1 (USE BLACK INK OR TYPE)

2. LA WITHHOLDING NO.

1. EMPLOYER NAME

4. FEDERAL EMP. I. D. NO.

3. TRADE NAME

6. FAX NO.

5. MAILING ADDRESS or P.O.BOX

CITY

STATE

ZIP CODE

7a. TEL.NO

7. PHYSICAL LOCATION IN LOUISIANA

CITY

STATE

ZIP CODE

(PHYSICAL LOCATION)

10. TEL. NO.

(ACCT. OR BKPR.)

8. ACCOUNTANT OR BOOKKEEPER WITH PAYROLL INFORMATION

9. EMAIL ADDRESS

11. TYPE OF

CORPORATION

PARTNERSHIP

INDIVIDUAL

NONPROFIT

GOVERNMENT

OTHER-

(SEE 13)

ORGANIZATION

SPECIFY

(CHECK ONE)

12. IF INCORPORATED:

DATE INCORPORATED

B. STATE OF INCORPORATION

13. IF YOUR ORGANIZATION IS A NONPROFIT ORGANIZATION. ATTACH A COPY OF ITS 501(C)(3) EXEMPTION FROM IRS.

14. LIST BELOW OWNER OF SOLE PROPRIETORSHIP, PARTNERS IN PARTNERSHIP, OR OFFICERS OF CORPORATION.

NAME & TITLE

SOC. SEC. NO

RESIDENCE

TEL. NO

15. DID YOU ACQUIRE ANY OF THE ORGANIZATION,TRADE,BUSINESS

IF YES, DID YOU

B IS THE BUSINESS ACQUIRED STILL

OR ANY ASSETS OF ANOTHER LOUISIANA EMPLOYER?

ACQUIRE

OPERATING IN LOUISIANA.

YES

PART

ALL

YES

C. NAME OF ORGANIZATION ACQUIRED.

D. THEIR LA. UNEMP. INS. NO.

E. DATE ACQUIRED

16. ADDITIONAL ORGANIZATION ACQUIRED

PART

ALL

THEIR LA. UNEMP. INS. NO.

DATE ACQUIRED

17. ENTER THE ACCOUNT NUMBER IF YOU HAVE AN EXISTING U. I. NUMBER.

LA UNEMP. INS. NO.

18. WAS THE PERSON OR ORGANIZATION NOTED IN NO, 1 SUBJECT

A. DATE SUBJECT TO

19. FIRST DAY OF WORK PERFORMED

TO FUTA (FEDERAL UNEMPLOYMENT TAX ACT)?

FUTA

IN LOUISIANA FOR EMPLOYER IN NO. 1

YES

21. THESE EMPLOYEES ARE (CHECK ONE )

20.

ENTER THE TOTAL NUMBER OF EMPLOYEES WORKING IN LOUISIANA

DURING EACH WEEK

OF THE CURRENT

AND PREVIOUS TWO CALENDAR YEARS STARTING WITH FIRST DAY OF

REGULAR

DOMESTIC

AGRICULTURAL

WORK.

(INCLUDE FULL–TIME,PART-TIME, COMMISSIONED & OFFICER OF CORP.)

CALENDAR YEAR

WEEK

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

22. TOTAL WAGES PAID IN LA.

( OR ESTIMATE )

BY QUARTER FOR THE CURRENT AND PREVIOUS TWO CALENDAR YEARS (INCLUDE FULL-

TIME, PART-TIME, COMMISSIONED & OFFICER OF CORP)

CALENDAR YEAR

QTR WAGES

CALENDAR YEAR

QTR WAGES

CALENDAR YEAR

QTR WAGES

*IN ORDER TO TRANSFER PART OF THE EXPERIENCE RATING RECORD OF THE PREDECESSOR, THE APPLICATION & AGREEMENT FOR PARTIAL TRANSFER MUST BE

SUBMITTED WITHIN 180 DAYS OF ACQUISITION.

LDOL-ES 1REV. 02/2000 PAGE 1 OF 2

Form Ldol-Es 1- Status Report

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