Form Nys 100 - New York State Employer Registration For Unemployment Insurance, Withholding, And Wage Reporting Page 3

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NYS 100 Page3
Legal Name: __________________________________ER Number: _________________________
1. Mailing Address: This is your business mailing address where your Withholding Tax (WT) and Unemployment
Insurance (UI) mail will be delivered. If you elect to have your UI mail directed to an address other than your place of
business, complete number 4 below.
ATTN: ________________________________________________________________________________________
Street or PO Box: _______________________________________________________________________________
City:__________________________________________ State: ___________ Zip Code:______________________
County: ________________________________________ Country: _______________________________________
2. Physical Address: This is the physical location of your business, if different from the Mailing Address in number 1.
Street: _______________________________________________________________________________________
City:__________________________________________ State: ___________ Zip Code:______________________
County: ________________________________________ Country: ______________________________________
3. Location of Books/Records: This is the physical location where you keep your Books and Records.
C/O (if applicable): ______________________________________________________________________________
Street: ________________________________________________________________________________________
City:__________________________________________ State: ___________ Zip Code:______________________
County: _______________________________________ Country: ________________________________________
(
)
-
Phone:
ext:____________________________
Contact Name:__________________________________________________________________________________
Optional Addresses
4. Agent Address (C/O): Complete this if your UI mail should be sent to an address other than your business address.
C/O: ________________________________________________________________________________________
Street or PO Box: ______________________________________________________________________________
City:__________________________________________ State: ___________ Zip Code:_____________________
County: _______________________________________ Country: _______________________________________
(
)
-
Phone:
ext:____________________________
Contact Name:________________________________________________________________________________
5. LO 400 Form - Notice of Potential Charges Address: This is sent each time a former employee files a claim for
Unemployment Insurance benefits. You can sign up for SIDES to receive this notice electronically. See instructions or
visit our website at
for additional information. Otherwise, complete below:
C/O: _________________________________________________________________________________________
Street or PO Box: ______________________________________________________________________________
City:__________________________________________ State: ___________ Zip Code:______________________
County: _______________________________________ Country: _______________________________________
(
)
-
Phone:
ext:____________________________
Contact Name:_________________________________________________________________________________
* Refer to NYS – 100 I for instructions.

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