Form C-1 - Status Report (Page 2 of 2) in pdf

8. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED - STREET (NOT RFD OR P.O. BOX #)

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

FAX NUMBER

9. DO YOU HAVE WORKERS PERFORMING SERVICES FOR YOUR BUSINESS WHOM YOU CONSIDER TO BE SELF-EMPLOYED OR INDEPENDENT

CONTRACTORS

YES

NO - IF YES, PLEASE ATTACH A LIST PROVIDING NAME, ADDRESS, TELEPHONE AND TYPE OF SERVICE PROVIDED/PERFORMED.

10. DID YOU ACQUIRE THE ORGANIZATION, TRADE, BUSINESS OR ANY ASSETS OF ANY OTHER VERMONT EMPLOYER?

YES - Complete items 11A-11F and 12.

NO, Go to item 12.

DID YOU INCORPORATE YOUR VERMONT PROPRIETORSHIP OR PARTNERSHIP?

YES - Account No.: ______________________________

If YES, Complete items 11A-11F.

No - Go to item 12.

11B. DATE ACQUIRED ________________________

11A. DID YOU ACQUIRE

ALL?

PART?

11C. UNEMPLOYMENT ACCOUNT NUMBER OF BUSINESS ACQUIRED ______________________

11D. NAME OF BUSINESS ACQUIRED _______________________________________________________________________________________________________

11E. NUMBER OF EMPLOYEES RETAINED FROM FORMER OWNER

NONE

SOME

ALL

HOW MANY? ________________________

11F. HOW WAS BUSINESS ACQUIRED? (check one)

PURCHASE

MERGER

FRANCHISE

ENTITY CHANGE

LEASE (SPECIFY NATURE OF THE LEASE _____________________________________________________________________________________________

12. HAVE YOU EVER HAD A VERMONT UNEMPLOYMENT ACCOUNT NUMBER FOR THIS BUSINESS OR ANY OTHER LEGAL BUSINESS ENTITY?

YES

NO IF YES, GIVE FULL BUSINESS NAME ____________________________________________________________________________________

NATURE OF BUSINESS ACTIVITY

13A. PROVIDE A DETAILED DESCRIPTION OF THE NATURE OF ACTIVITY

13B. LIST PRINCIPLE PRODUCT(S) OR SERVICES, IN ORDER OF IMPORTANCE.

IN VERMONT.

13C. PLEASE SELECT THE APPROPRIATE CATEGORY BELOW WHICH CLOSELY DESCRIBES YOUR BUSINESS IN VERMONT. IF YOU HAVE MULTIPLE

BUSINESS TYPES, PLEASE SPECIFY THE PERCENTAGES IN 13A ABOVE. PLEASE BE SURE TO PROVIDE DETAILS IN 13A AND 13B..

Agriculture, Forestry, Fishing and Hunting

Transportation & Warehousing

Educational Services

Mining

Information

Health Care & Social Assistance

Utilities

Finance & Insurance

Arts, Entertainment & Recreation

Construction

Real Estate & Rental & Leasing

Accommodation & Food Services

Manufacturing

Professional, Scientific & Technical Services

Other Services (Except Admiistrative)

Wholesale Trade

Management of Companies & Enterprises

Public Administration

Retail Trade

Administrative & Waste Services

IF YOU ARE UNSURE OF THE CATEGORY IN WHICH YOUR BUSINESS FALLS, CONTACT LABOR MARKET INFORMATION AT (802) 828-3868 OR ACCESS THE WEB

AT FOR MORE INFORMATION.

If more than ONE Location, attach a list specifying

14. ENTER THE NUMBER OF ESTABLISHMENTS THE ABOVE BUSINESS OPERATES IN VERMONT.

each location with the STREET ADDRESS, CITY AND

INCLUDE: Home(s) of personnel, when the company does not have an office or worksite in Vermont.

THE NUMBER OF WORKERS AT EACH LOCATION.

EXCLUDE; Locations that are temporary (exist less than 1 year) or not staffed on a regular basis.

15. The following information is necessary as future notices will be available electronically. If the general contact is also responsible for UI Tax and Benefit information, enter

"Same" in those areas.

UI General Contact*

UI Tax Contact

UI Benefit Contact

INTERNAL contact if other contacts fail:

Person/Service that completes UI Tax Returns

Person/Service that completes separations/wage requests

E-MAIL*: ________________________________

* REQUIRED

16. SIGNATURE OF OWNER, PARTNER, OFFICER OF CORP., OR HEAD OF HOUSEHOLD

Form C-1 - Status Report Page 2

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