Form Dws-U1 - Status Report - Utah Department Of Workforce Services
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1Utah Department of Workforce Services
DWS-U1
Form 1
Unemployment Insurance
Rev. 5/01
140 East 300 South
P.O. Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9400
FAX (801) 526-9377
STATUS REPORT
READ INSTRUCTIONS ON REVERSE SIDE THEN COMPLETE ALL ITEMS
(TYPE OR PRINT LEGIBLY)
1. Type of Ownership
Individual
Partnership
Corporation
LLC
Other
2. Corporation, trade or business name and mailing address for quarterly contribution (tax) reports:
4. Federal Employer Identification Number (FEIN):
5. County in Utah where
6. Number of permanent
principal activity
worksites in Utah:
is located:
3. Telephone Number: (
)
Fax Number: (
)
7. Mailing address for Wage and Separation
8. Street address of principal permanent work
9. Street address of business headquarters
Requests (if different from item 2):
site in Utah (if different from items 2, 7, or 9):
(if different from item 2):
Telephone Number: (
)
Telephone Number: (
)
Telephone Number: (
)
Fax Number: (
)
Fax Number: (
)
Fax Number: (
)
10. List sole proprietor, general partners, corporate officers or LLC members:
Name
SSN
Title
Home/Address
Home Phone
(
)
(
)
(
)
11. Describe in detail your principal business product and/or service:
12. If you are a new business in Utah,
show date business started:
READ INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING ITEMS 14-14e
13. Date of first payment of wages in Utah:
14. Did you acquire the organization, trade, or business of another operator?
Yes
No
Type of acquisition:
Change of ownership
Merger or reorganization
Sale, lease or sub-lease
Purchased assets through court
Other, please explain:
14a. Name, address and UI account number (if available) of previous owner (predecessor):
#
Date acquired
14b. Did you acquire all or a portion of the predecessor’s organization, trade or business?
90% or more
Less than 90%
14c. Did you retain all of the predecessor’s employees?
Yes
No
14d. Is your predecessor still in business?
Yes
No
14e. Was predecessor’s business closed prior to acquisition?
Yes
No
Date closed ________________
15. Enter below the amount of wages you have paid in Utah. If you have not paid wages enter “NONE.”
Jan. 1 to Mar. 31
Apr.1 to Jun. 30
Jul. 1 to Sep. 30
Oct. 1 to Dec. 31
Current
Year:
Preceding
Year:
16. If you have not paid wages, do you expect to in the future?
Yes
No
Estimated date _____________________
I certify that the information contained in this report is true and correct.
(
)
Name
Title
Telephone Number
Date
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