Form C-1 - Status Report - Vermont Department Of Employment & Training
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2VERMONT DEPARTMENT OF EMPLOYMENT & TRAINING
P.O. BOX 488
VERMONT EMPLOYER NUMBER
MONTPELIER, VERMONT 05601-0488
STATUS REPORT C-1 (5/05)
FAX: (802) 828-4248
COMPLETE BOTH SIDES OF THIS FORM, AND RETURN WITHIN 10 DAYS.
YOU WILL BE INFORMED OF YOUR VERMONT UI LIABILITY
1. FEDERAL ID NUMBER
5. MAILING ADDRESS
STREET
2. EMPLOYER'S LEGAL NAME
3. TRADE OR DBA NAME (LIST ALL)
CITY
STATE
ZIP CODE
5A. E-MAIL ADDRESS/WEB ADDRESS
5B.TELEPHONE NUMBER 5C. FAX NUMBER
4. ATTENTION OR C/O NAME
6. TYPE OF ORGANIZATION (CHECK ONE)
SOLE-PROPRIETORSHIP OR DOMESTIC
PARTNERSHIP
CO-OWNER (Husband/Wife or Civil Union Partners)
LIMITED LIABILITY COMPANY (LLC/LLP)
ASSOCIATION
TRUSTEE IN BANKRUPTCY
501 (c)(3) CORPORATION, ATTACH IRS EXEMPTION
CORPORATION, SPECIFY STATE AND DATE OF INCORPORATION ___________________________
6A. LIST BELOW THE OWNER(S), PARTNERS, MEMBERS/MANAGERS OR OFFICERS:
NAME
SOCIAL SECURITY NO.
TITLE
HOME ADDRESS (NO P.O. BOXES)
7A. FIRST DATE OF EMPLOYMENT IN VERMONT: _______________________________ DATE FIRST WAGES PAID IN VERMONT: _______________________________
7B. HAS YOUR ORGANIZATION PAID FEDERAL UNEMPLOYMENT TAX?
NO
YES, LIST YEARS ______________________________________________
7C. ENTER THE NUMBER OF WORKERS FOR EACH WEEK AND LIST TOTAL GROSS WAGES PAID FOR EACH CALENDAR QUARTER EMPLOYMENT OCCURRED. IF
EMPLOYMENT OCCURRED PRIOR TO THE CALENDAR YEAR LISTED BELOW, PLEASE ATTACH ADDITIONAL SHEETS WITH THE NEEDED INFORMATION.
DO NOT ESTIMATE FUTURE WAGES.
ENTER QUARTERLY
CALENDAR YEAR 2005
GROSS WAGES PAID
1-Jan
8-Jan
15-Jan
22-Jan
29-Jan
5-Feb
12-Feb
19-Feb
26-Feb
5-Mar
12-Mar
19-Mar
26-Mar
2-Apr
9-Apr
16-Apr
23-Apr
30-Apr
7-May
14-May
21-May
28-May
4-Jun
11-Jun
18-Jun
25-Jun
2-Jul
9-Jul
16-Jul
23-Jul
30-Jul
6-Aug
13-Aug
20-Aug
27-Aug
3-Sep
10-Sep
17-Sep
24-Sep
1-Oct
8-Oct
15-Oct
22-Oct
29-Oct
5-Nov
12-Nov
19-Nov
26-Nov
3-Dec
10-Dec
17-Dec
24-Dec
ENTER QUARTERLY
GROSS WAGES PAID
CALENDAR YEAR 2004
3-Jan
10-Jan
17-Jan
24-Jan
31-Jan
7-Feb
14-Feb
21-Feb
28-Feb
6-Mar
13-Mar
20-Mar
27-Mar
3-Apr
10-Apr
17-Apr
24-Apr
1-May
8-May
15-May
22-May
29-May
5-Jun
12-Jun
19-Jun
26-Jun
3-Jul
10-Jul
17-Jul
24-Jul
31-Jul
7-Aug
14-Aug
21-Aug
28-Aug
4-Sep
11-Sep
18-Sep
25-Sep
2-Oct
9-Oct
16-Oct
23-Oct
30-Oct
6-Nov
13-Nov
20-Nov
27-Nov
4-Dec
11-Dec
18-Dec
25-Dec
8. VERMONT PHYSICAL LOCATION WHERE SERVICES ARE PERFORMED (Attach additional sheet if necessary) _________________________________________________
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 SERVICES PROVIDED/PERFORMED.
DEPARTMENT USE ONLY
STATUS NAICS
COUNTY
TOWN
LMI NAICS
LIABLE
NO
YES
REPORTS DUE
NONE
EXAMINED BY
DATE
LIABLE
ESTAB
IN UC
MAIL
TICKLE DATE
LIAB CODE
TYPE
NEW
ACS
PREDECESSOR OR OLD NO.
RATES
RTA, SAME NO.
PARTIAL
______________________________
RTA, NEW NO.
FULL, TRANSFER EXPERIENCE
CONTINUED ON BACK
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