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Ohio Department of Job and Family Services
REPORT TO DETERMINE LIABILITY
Attention: Contribution Section
P.O. Box 182404
Columbus, Ohio 43218-2404
(614) 466-2319 extension 22485
1.a. Employer Name
1.b. Employer Trade name (if any)
1.c. Telephone #
1.d. E-mail Address
1.e. Physical Business Address (street)
(city)
(state)
(zip)
1.f. Mailing Address (if different) (street)
(city)
(state)
(zip)
2.a.
Type of business operation:
Individual
Partnership
Association
Joint Venture
Limited Liability Company
Corporation (state of inc.)
(date of inc.)
(charter #)
Fiduciary (type)
Other (explain)
2.b.
Provide the following information regarding the employer’s principal members (individual, partners, corporate officers, etc.).
(If not sufficient space, attach supplemental sheet.)
Name
S.S.#
Home Address
Name
S.S.#
Home Address
3.a. On what date did you begin operations in Ohio?
3.b. On what date did you first employ one or more workers in Ohio?
(include corporate officers)
4.
Was the trade or business previously operated by another employer?
5.a. Have you previously been subject to the Ohio Unemployment
Yes
No
If “Yes” complete JFS 66302
Compensation Law?
Yes
No
5.b. If yes, provide: (name)
(ODJFS account #)
6.
Provide your federal employer identification # (I.R.S.)
7.a. Have you paid wages which were taxable under the Federal Unemployment Tax Act (FUTA)?
7.b. If yes, indicate which years.
Yes
No
8.a. Is your enterprise exempt from federal income taxes under section
8.b. If yes, attach a copy of the exemption letter issued by the Internal
501 ( c )(3), Internal Revenue Code?
Yes
No
Revenue Service.
9.a. Describe fully the type of business you operate. Do you have more than one place of business or employment in Ohio?
Yes
No
OHIO county in which workers are
Number of Workers
Nature of business, including services performed
Materials Used
employed
and products manufactured or sold. (If engaged in trade,
(If manufacturing)
indicate retail or wholesale).
9.b. Is the establishment primarily engaged in performing services for other units of the company?
Yes
No
If “YES”, indicate nature of activity:
Central Administrative Office
Storage (warehouse)
Research, Development or Testing
Other (specify)
Note: If you have any questions regarding question 9.a. or 9.b., please telephone (614) 644-2689.
JFS 66300 (Rev. 4/2010)
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