Form Ibr-1 - Unemployment Insurance Status Report / State Tax Commission / Industrial Commission- Idaho Department Of Labor
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1
2
3
4Revised
TC00071
IBR-1
UNEMPLOYMENT INSURANCE STATUS REPORT
6-3-97
1997
County Code
Industry Code
Account Number
DEPARTMENT OF LABOR
STATE OF IDAHO
Add Code 1
Add Code 2
Cov. Code
DBA Code
Alpha
Date Liable
New Account Code
Field Rep Code
317 MAIN STREET
Yr_________ Mo_________ Day________
BOISE, IDAHO 83735-0760
Too
Cont
Pred. Number
COMPLETE BOTH SIDES OF THIS FORM
SHADED AREAS FOR STATE USE ONLY
Type of
___Sole proprietorship
___Partnership
___S Corporation
___Corporation
___Limited Liability Partnership
1 .
business
___Nonprofit
___Government
___Fiduciary/Trust
___Limited Liability Corporation
___Limited Liability Sole Proprietorship
3. State incorporated in
4. Tax year end
5. Date business began
2 .
Date incorporated
7 . ___Amusement device decals
6 .
Type of permit/account
___Unemployment
___Withholding
___Sales
Number of decals requested
___Boise Auditorium
___ Travel & Convention
___Use
__________ X $35.00 =
___New business ___Change business name ___Change legal name ___New location
8 .
Purpose of registration
___Add new permit type ___Change in partners or shareholders _____%
10. Social security number (SSN)
Total Due_______________
9 .
Federal employer identification number (EIN)
12. Assumed business name/DBA
1 1 .
Legal business name (see instructions)
Street address or PO Box
City
State
Zip Code
1 3 .
Mailing address
Street address
City
County
State
Zip Code
1 4 .
Physical location of
business (see instructions)
Street address or PO Box
City
State
Zip Code
1 5 .
Mailing address
for report forms
1 6 .
Contact person (name and title)
17. Telephone number
(
)
18. Primary nature of business in Idaho:
(describe product/service)
20. Date employees first hired
21. Date of employees' first paycheck in Idaho
22. Expected number of
1 9 .
Date sales/use will begin in Idaho
Idaho employees
2 3 .
Did you previously have a withholding, sales, use, workers' compensation or unemployment insurance number in Idaho? If yes, list all permit,
account, or policy numbers.
2 4 .
Did you acquire an existing business?
Yes
No
Previous business and owner's name
2 5 .
Workers' compensation needed: THIS IS NOT AN APPLICATION FOR WORKERS' COMPENSATION INSURANCE (see instructions).
Yes
No, explain why.
2 6 .
Workers' compensation obtained:
Yes
No
In process
Insurance company name
Policy number
Effective date
Agent's name
Telephone number
2 7 .
Do you plan to perform work in other states, using your existing Idaho employees?
Yes
No
Which states?
2 8 .
List (a) owner, spouse, (b) partners, or (c) corporate officers (Use additional sheet if necessary.)
Corporate
SSN or EIN
Name
Address of Residence
Director?
% Owned
Title
CERTIFICATION: I certify that I am authorized as an owner, partner, corporate officer or representative to sign this document and that the statements
made are correct to the best of my knowledge. (This form must also be signed by the spouse of a sole proprietor.)
Signature ___________________________________ Date_________________
Signature __________________________________ Date ________________
Signature ___________________________________ Date_________________
Signature __________________________________ Date________________
Received Quarterly Reports
Send quarterly reports
For Department Use Only
Send cover letter: ___Yes ___No
Date due:
Keypunch date
S D X
Send rate transfer info: ___All ___Part
O V E R
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