Form 60-0126 - Report To Determine Liability - 2009

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FOR ADMINISTRATIVE USE ONLY

DOCUMENT CONTROL DATE

ACCOUNT NUMBER

FORM NUMBER

IOWA EMPLOYER ACOUNT NUMBER

APPROVED BY

DATE

DESCRIPTION

PREDECESSOR’S NUMBER

Law Citation

DESCRIPTION CONTINUED

For Administrative

Office Use Only

96.19-16

1. Direct W/O FIN

4. Third W/O FIN

7. APB W/O FIN

REPORT TO DETERMINE LIABILITY

Form 60-0126 (Revised 5/09)

2. Direct OOS FIN

5. Third OOS FIN

8. APB OOS FIN

3. Direct IA FIN

6. Third IA FIN

9. APB IA FIN

NAICS

AREA

SIC CODE

Iowa Workforce Development

1000 East Grand Avenue

DETER. DATE/MERGER DATE

EFFECTIVE DATE

Des Moines, Iowa 50319-0209

CURR. RATE

ELIG. YEAR

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DECISION LETTER

VARIABLE

CODE

(See Instructions for phone numbers)

1. Type of Organization

2. Federal Identification Number

Corporation

(FEIN):

Individual Ownership

S Corporation

3. Date Organization Registered:

Partnership

Governmental

4. Organization Registered In

What State:

Limited Liability Partnership (LLP)

Non-profit (501(C)(3) Organization)

5. Current Iowa Unemployment

Limited Liability Company (LLC)

Other

Account Number, If Assigned:

6. LIST NAME OF OWNER, PARTNERS,

SOCIAL SECURITY NUMBER

RESIDENT ADDRESS

MEMBERS OR CORPORATE OFFICERS

7. CORPORATION / LLC NAME

BUSINESS OR TRADE NAME

8. ADDRESS FOR MAILING TAX REPORTS

(PO BOX)

(ZIP CODE+4)

(COUNTY#)

(STATE)

(CITY OR TOWN)

Alternate Telephone Number

Business Telephone Number

9. Are you required to file the Federal Unemployment Tax Return

Yes

(+Area Code)

(FUTA for either the current or preceding year?

10. DATE YOU BEGAN EMPLOYING WORKERS

DATE YOU FIRST PAID

IN IOWA

WORKERS IN IOWA

(IF MORE THAN ONE LOCATION, ATTACH SEPARATE LIST -- IF SAME AS NUMBER 8 , CHECK HERE

AND SKIP NUMBER 11.)

(ZIP CODE+4)

11. LOCATION WHERE

CITY OR TOWN

STATE

COUNTY#

ADDRESS

WORK IS

PERFORMED IN IOWA

12. NATURE OF BUSINESS ACTIVITY IN IOWA

**** (MUST SHOW BOTH BUSINESS ACTIVITY AND DETAILED DESCRIPTION) ****

PRIMARY BUSINESS ACTIVITY

In the space below give details of the primary Iowa business activity (See Reference Guide)

13. FOR EACH OF THE FOLLOWING CALENDAR QUARTERS, ENTER THE GROSS QUARTERLY WAGES PAID IN IOWA

1ST QUARTER

2ND QUARTER

3RD QUARTER

4TH QUARTER

CURRENT YEAR:

PRECEDING YEAR:

IF YOUR COMPANY IS A NON-PROFIT ORGANIZATION EXEMPT FROM INCOME TAX UNDER U.S. INTERNAL REVENUE CODE 26 U.S.C. 501 (C)(3),

PLEASE ATTACH A COPY OF THE LETTER FROM THE IRS CONFIRMING THIS CLASSIFICATION.

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