Form Uct-43 - Preliminary Report - 2012
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1
2PRELIMINARY REPORT FOR 2012
Send to: Department of Workforce Development
Division of Unemployment Insurance
Required to determine your status under the Wisconsin
P.O. Box 7942
Unemployment Insurance Act, (CHAPTER 108, WIS.
Madison, Wisconsin 53707-7942
Telephone: (608) 261-6700
STATS.) COMPLETE AND RETURN THIS REPORT WITHIN
FAX: (608) 267-1400
10 DAYS UNLESS INSTRUCTED OTHERWISE.
email: taxnet@dwd.wisconsin.gov
Complete 1-5 If different from address at left,
then proceed with number 6:
UI Account Number
1. Legal Name
2. Trade Name (D/B/A)
3. Mailing Address c/o (If required for correct delivery)
4. Street or P.O. Box
5. City
State
Zip Code
6. Federal Identification Number (9 digits)
7. Person To Contact For Additional Information:
Name
Telephone Number
8
(
)
Limited Liability Company
8. Check Type of Ownership:
8
8 8 8
Limited Liability Company Electing to be
Individual
Treated as Corp for Federal Tax Purposes
12. Nature of Business in Wisconsin:
Partnership
You must submit a copy of your IRS
Corporation
8
8 8
Notice of Acceptance
Other (Estate, Trust, Receivership)
Limited Liability Partnership
- Identify
Limited Partnership
9. Provide Name(s) and Social Security Number(s) of Sole Owner;
Partners; Members; or Corporate Officers:
Name(s)
S.S. No.(s)
13. Did you acquire any portion of an
Yes
No
already established Wisconsin business?
If yes, complete:
Date of Acquisition:
Legal Name of Prior Owner:
UI Account Number
10. Wisconsin Employment Began: (month/day/year)
Trade Name of Prior Owner:
11. Location of Wisconsin Activity:
Street Address
Current Address of Prior Owner: (Street or P.O. Box)
City
State
Zip Code
City
State
Zip Code
WISCONSIN
14. In the table below show
payroll and number of employees to date. Include ONLY individuals hired for work exclusively or
WISCONSIN
generally in
whether they are Wisconsin or out-of-state residents. Also, include any employee whose services have become
localized in Wisconsin upon transfer to Wisconsin employment. Do not include wages paid to persons from permitted exclusions listed on page 4.
2010
2011
2012
QTR.
GROSS PAYROLL
NO. OF EMPLOYEES
GROSS PAYROLL
NO. OF EMPLOYEES
GROSS PAYROLL
NO. OF EMPLOYEES
1st
2nd
3rd
4th
COMPLETE THE SECOND PAGE OF THIS REPORT
UCT-43 (R. 10/25/2011) (U00021)
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