Form1g - School And Government Status Report 2010
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1
2DWS-UI
Utah Department of Workforce Services
Form1G
Unemployment Insurance
Rev.
05/10
140 East 300 South P.O. Box 45288 Salt Lake City, UT 84145-0288
(801) 526-9235 option 2
1-800-222-2857 option 2
Fax: (801) 526-9377
s
s
SCHOOL AND GOVERNMENT
STATUS REPORT
Please Read the Instructions then Complete All Items. Type or Print Legibly.
City Government
County Government
State Government
Other: ___________________
1. Type of Organization:
Charter School (See instructions)
School District
2a. Telephone:
2. Name and mailing address for UI quarterly reports:
3a. Federal Employer ID Number
(
)
(FEIN):
2b. Fax:
3b. Utah Unemployment
Registration Number:
(
)
2c. E-mail:
4. County in Utah
Number of
5.
where principal
permanent
activity is located:
work sites:
6. Mailing Address for Wage and Separation
7. Street address & phone of principal work
8. Mailing address & phone for New-Hire information
Requests (if different from item 2.)
site in Utah (if different from item 2):
(if different than item 2):
Telephone # (
) _______________
Telephone # (
) ____________
Telephone # (
) _______________
9. List organization officers names and social security numbers:
Name
SSN
Name
SSN
10.
11.Date Organization began operation:
Describe your principal business product and/or service of your Utah operation (see instructions):
Elected Method of Reporting and Payment:
12.
IMPORTANT -- This decision must be made by individual(s)
with the authority to make a financial commitment for the
organization. (See instructions)
a. Reimbursement of Unemployment Benefits Paid
The above organization elects to reimburse the Unemployment Insurance Fund an amount equal to the amount of regular benefits and of
one-half of the extended benefits paid that is attributable to service performed by former employees of the above organization. This
election requires the filing of quarterly employment and wage reports.
b. Payment of Quarterly Contributions
The above organization elects to file quarterly reports and pay any contributions as required by Section 35A-4-302 of the Utah
Employment Security Act. Tax Rate is determined by business activity described in item 10 above.
Enter below the amount of wages you have paid in Utah. If you have not paid wages, enter "NONE":
13.
Jan. 1 to Mar. 31
Apr. 1 to Jun. 30
Jul. 1 to Sep. 30
Oct. 1 to Dec. 31
Current Year:
$
$
$
$
Preceding Year:
$
$
$
$
NO.
YES: Estimated Date: ____________
14.
If you have not paid wages, do you expect to pay wages in the future?
I certify that the information contained in this report is true and correct
Signature:__________________________________
Print Name & Title:__________________________________
Telephone:__________________________________
Date: ___________________________________________
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