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Form Uc-1 - Report To Determine Liability And If Liable Application For Employer Account Numeber

UC-1 1/98

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STATE OF DELAWARE

DEPARTMENT OF LABOR

Document 60-06/98/01/01

Division of Unemployment Insurance

PO Box 9953 Wilmington DE 19009-0953

302-761-8482

)

(DO NOT FILL IN THIS SPACE

This report is to be filled in and returned to

REPORT TO DETERMINE LIABILITY

Employer Number______________

this office within 10 days of receipt whether

AND IF LIABLE

Ind. Code and Area_____________

or not you are liable for assessments under

APPLICATION FOR

Effective Date of Liability________

Part III, Title 19, Delaware Code

EMPLOYER ACCOUNT NUMEBER

Assessment Rate_______________

Status Date____________________

FILL IN WITH TYPEWRITER OR PRINT IN INK

- ALL QUESTIONS MUST BE ANSWERED

Name of Employer and Trade Name, if any.

Have you:

1. Started new business

2. Purchased going business (Attach Explanation)

1a. Federal Employer's Identification Number

3. Just begun having employment

4. Reorganization (Attach Explanation)

5. Other (Attach Explanation)

Street Address and Telephone Number of Main Office

Ownership Information

Is Business Publicly Held Yes

If yes, provide name and Federal Identification Number

3. Address to which employer's report forms and mail are to be

of controlling entity.

If no, complete ownership information below. If more

sent. Outside representative must file a power of attorney.

than one owner, attach additional information. percentage

of ownership must total 100%

Name

3a. E-Mail Address:

Social Security Number

4. Have you previously filed an application for a Delaware

Addresses

Account number?

Yes.

% of Ownership

7. On what date did you first employ any

8. Are you liable as an employer under

Do you own or control any other

workers in Delaware?

the Unemployment Compensation Laws

employing unit in Delaware?

in any other State?

Will Gross Payroll meet or exceed

$1,500.00 in either the 3

or 4

Yes

Quarter? Yes

Yes

Account #______________

10. State total number of workers in covered employment in Delaware and total payroll by calendar quarters. If

11, Check form of

unknown, estimate total number of works and total payroll by calendar quarter

organization

MARCH

JUNE

SEPT.

DEC.

Individual

Partnership

Employees

Payroll

Employees

Payroll

Employees

Payroll

Employees

Payroll

Delaware Corporation

1995

Out-Of-State Corporation

1996

Non-Profit

1997

Estate or Trust

1998

Other (specify Below)

1999

11a. Date of Incorporation

COMPLETE REPORT ON REVERSE SIDE AND SIGN

Form Uc-1 - Report To Determine Liability And If Liable Application For Employer Account Numeber

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