Form Esd-Ark-201 - Status Report printable pdf download

STATUS REPORT

REPORT TO DETERMINE LIABILITY UNDER THE ARKANSAS EMPLOYMENT SECURITY LAW

ARKANSAS EMPLOYMENT SECURITY DEPARTMENT P. O. Box 2981 - Little Rock, AR 72203-2981 Telephone (501) 682-3268

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IDENTIFICATION SECTION

1 . ACCOUNT NUMBER ASSIGNED BY ESD (IF ANY)

2. FEDERAL EMPLOYER I.D. NUMBER

TYPE OF OWNERSHIP (CHECK ONE)

❏

CORPORATION

INDIVIDUAL

LIMITED

STATE

TRUST

(SOLE PARTNERSHIP)

PARTNERSHIP

AGENCY

❏

PARTNERSHIP

PROFESSIONAL

ESTATE

POLITICAL

ASSOCIATION

SUBDIVISION

IF THE TYPE OF BUSINESS IS A CORPORATION ENTER THE CORPORATE NAME IN ITEM 4 BELOW.

4. NAME

5. MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

(

)

6. ENTER THE NAME (OR FIRM NAME) AND BUSINESS ADDRESS WHERE RECORDS OR PAYROLLS ARE KEPT (IF DIFFERENT FROM ITEM #5).

NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

(

)

If the type of ownership is an individual or partnership, enter the name(s) and social security number(s) as applicable below, or

if the type of ownership is a corporation, complete the information for two officers. Do not list Board Members or Directors.

NAME

SOCIAL SECURITY NUMBER

TITLE

RESIDENCE ADDRESS, CITY, STATE, ZIP

OWNERS OR

CORPORATE

OFFICERS

ATTACH

ADDITIONAL

SHEET IF

NECESSARY

No. of Employees

TRADE NAME

STREET ADDRESS, CITY, ZIP, COUNTY

TELEPHONE NO.

BUSINESS

LOCATION

IN ARKANSAS

ATTACH

ADDITIONAL

SHEET IF

NECESSARY

CHARTER NUMBER

STATE INCORPORATED

DATE INCORPORATED

REGISTERED AGENT’S NAME

YOUR

BUSINESS

IS A CORPORATION,

ORIGINAL CORPORATE NAME, IF DIFFERENT THAN ABOVE

REGISTERED AGENT’S ADDRESS

ENTER:

10.

PREVIOUS OWNER’S ACCOUNT NUMBER (IF KNOWN)

MONTH

DAY

YEAR

DATE OF ACQUISITION:

IF THE BUSINESS

IN ARKANSAS

NAME OF PREVIOUS OWNER

ADDRESS

CITY

STATE

WAS ACQUIRED

FROM ANOTHER

❒

LEGAL ENTITY

WHAT PORTION OF THE

(CHECK)

ALL.

ENTER:

❒

BUSINESS WAS ACQUIRED?

(ONE)

PART (SPECIFY PERCENTAGE) ________________________

EMPLOYMENT SECTION

11.

MONTH

DAY

YEAR

ENTER THE DATE YOU BECAME LIABLE FOR STATE UNEMPLOYMENT (HAD ONE OR MORE EMPLOYEES

IN SOME PART OF TEN DAYS) (ACA 11-10-209)(1) OF ESD LAW. SEE INSTRUCTIONS

12.

IF YOUR ACCOUNT HAS

ENTER THE DATE YOUR ORGANIZATION RESUMED EMPLOYING

BEEN INACTIVE:

SOMEONE IN ARKANSAS.

13.

IF YOU ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE OF 1954 SECTION 501 (C)(3), ATTACH A COPY OF YOUR EXEMP-

❒

TION LETTER. INDICATE YOUR PREFERENCE:

REIMBURSE

CONTRIBUTION

DOMESTIC - HOUSEHOLD EMPLOYMENT SECTION

COMPLETE 14 ONLY IF YOU HAVE DOMESTIC OR HOUSEHOLD EMPLOYEES

(INCLUDES MAIDS, COOKS, CHAUFFERS, SITTERS, ETC.)

14.

MONTH

DAY

YEAR

ENTER THE ENDING DATE OF THE FIRST CALENDAR QUARTER IN WHICH YOU PAID GROSS WAGES OF $1000 OR MORE

TO EMPLOYEES PERFORMING DOMESTIC SERVICE:

PAYROLL REPORTING SECTION

15.

❒

ARE YOU AN EMPLOYEE LEASING EMPLOYER? ........................................................................................................................................................

YES

❒

ARE YOUR PAYROLL RECORDS MAINTAINED ON COMPUTERIZED FILES? ...........................................................................................................

YES

❒

DO YOU WISH TO REPORT BY MAGNETIC MEDIA? IF YES, INDICATE YOUR PREFERENCE:

.......................................

DISC

TAPE

CARTRIDGE

ESD-ARK-201 (Rev. 1-03) PAGE 1 OF 2

(CONTINUED ON REVERSE SIDE)