Form C-1 - Employer Status Report printable pdf download

VERMONT DEPARTMENT OF LABOR

ATTN: EMPLOYER SERVICES

TELEPHONE: 802-828-4344

VERMONT EMPLOYER NUMBER

FAX: 802-828-4248

P.O. BOX 488

STATUS REPORT C-1 (12/14)

MONTPELIER, VERMONT 05601-0488

INCOMPLETE FORMS WILL

COMPLETE BOTH PAGES OF THIS FORM, AND RETURN WITHIN 10 DAYS

OR GO TO 'EMPLOYER ONLINE SERVICES' AT

DELAY REGISTRATION.

YOU WILL BE INFORMED OF YOUR VERMONT UI LIABILITY

1. FEDERAL ID NUMBER

2. EMPLOYER'S LEGAL NAME

5. MAILING ADDRESS

STREET

3. TRADE OR DBA NAME (LIST ALL)

CITY

STATE

ZIP CODE

4. ATTENTION OR C/O NAME

5A. E-MAIL ADDRESS/WEB ADDRESS

5B. TELEPHONE NUMBER

5C. FAX NUMBER

6. TYPE OF ORGANIZATION (CHECK ONE)

SOLE-PROPRIETORSHIP OR DOMESTIC

PARTNERSHIP

CO-OWNER (Husband/Wife or Civil Union Partners)

MUST ATTACH IRS EXEMPTION

501 (c)(3) CORPORATION,

ASSOCIATION

TRUSTEE IN BANKRUPTCY

LIMITED LIABILITY COMPANY (LLC/LLP/L3C)

CORPORATION, SPECIFY STATE AND DATE OF INCORPORATION ______________________________________________

6A. LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS:

NAME

SOCIAL SECURITY NO.

TITLE

HOME ADDRESS (NO P.O. BOXES)

MULTISTATE WORKERS

7. DO YOU HAVE EMPLOYEE(S) WHO WORKED FOR YOU IN ANOTHER STATE BEFORE WORKING IN VERMONT?

YES

7A. FIRST DATE OF EMPLOYMENT IN VERMONT: ______________________ DATE FIRST WAGES PAID IN VERMONT: _______________________

7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX ON WAGES PAID IN ANOTHER STATE IN PRIOR YEARS?

YES, LIST YEARS

______________________________________________

7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND THE TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED.

IF EMPLOYMENT OCCURRED PRIOR TO THE CALENDAR YEARS LISTED BELOW, PLEASE ATTACH ADDITIONAL SHEETS WITH THE NEEDED INFORMATION.

DO NOT ESTIMATE FUTURE WAGES.

A WORKER IS ANYONE PERFORMING SERVICES FOR YOUR BUSINESS, UNLESS THEY ARE EXEMPT UNDER UNEMPLOYMENT.

CALENDAR YEAR 2015 - ENTER NUMBER OF WORKERS IN EACH WEEK

ENTER QUARTERLY GROSS WAGES PAID

3-Jan

14-Feb

10-Jan

17-Jan

24-Jan

31-Jan

7-Feb

21-Feb

28-Feb

7-Mar

14-Mar

21-Mar

28-Mar

4-Apr

11-Apr

18-Apr

25-Apr

2-May

9-May

16-May

23-May

30-May

6-Jun

13-Jun

20-Jun

27-Jun

18-Jul

25-Jul

29-Aug

5-Sep

4-Jul

11-Jul

1-Aug

8-Aug

15-Aug

22-Aug

12-Sep

19-Sep

26-Sep

21-Nov

19-Dec

17-Oct

24-Oct

31-Oct

7-Nov

14-Nov

28-Nov

5-Dec

12-Dec

26-Dec

3-Oct

10-Oct

CALENDAR YEAR 2014 - ENTER NUMBER OF WORKERS IN EACH WEEK

ENTER QUARTERLY GROSS WAGES PAID

8-Mar

15-Mar

4-Jan

11-Jan

18-Jan

25-Jan

1-Feb

8-Feb

15-Feb

22-Feb

1-Mar

22-Mar

29-Mar

5-Apr

12-Apr

19-Apr

26-Apr

3-May

10-May

17-May

24-May

31-May

7-Jun

14-Jun

21-Jun

28-Jun

5-Jul

12-Jul

19-Jul

26-Jul

2-Aug

9-Aug

16-Aug

23-Aug

30-Aug

6-Sep

13-Sep

20-Sep

27-Sep

22-Nov

6-Dec

29-Nov

13-Dec

4-Oct

11-Oct

18-Oct

25-Oct

1-Nov

8-Nov

15-Nov

20-Dec

27-Dec

DEPARTMENT USE ONLY

STATUS NAICS

COUNTY

TOWN

LMI NAICS

LIABLE

YES

REPORTS DUE

NONE

EXAMINED BY

DATE

LIABLE

ESTAB

IN UC

MAIL

TICKLE DATE

LIAB CODE

TYPE

NEW

ACS

PREDECESSOR OR OLD NO.

RATES

RTA, SAME NO.

PARTIAL

______________________________

RTA, NEW NO.

FULL, TRANSFER EXPERIENCE

CONTINUED ON PAGE 2

Form C-1 - Employer Status Report

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