Form 60-0126 - Report To Determine Liability - 2006 printable pdf download

FOR ADMINISTRATIVE USE ONLY

IOWA EMPLOYER ACOUNT NUMBER

APPROVED BY

DATE

PREDECESSOR’S NUMBER

Law Citation

ACCOUNT NUMBER

FORM NUMBER

DOCUMENT CONTROL DATE

60-0126

96.19-16

DESCRIPTION

1. Direct W/O FIN

4. Third W/O FIN

7. APB W/O FIN

2. Direct OOS FIN

5. Third OOS FIN

8. APB OOS FIN

DESCRIPTION (CONTINUED)

FOR

3. Direct IA FIN

6. Third IA FIN

9. APB IA FIN

ADMINISTRATIVE

USE ONLY

NAICS

AREA

SIC CODE

REPORT TO DETERMINE LIABILITY

Form 60-0126 (09-06)

DETER. DATE/MERGER DATE

EFFECTIVE DATE

Iowa Workforce Development

1000 East Grand Avenue

ELIG. YEAR

CURR. RATE

��

� � � � � � � � � �

Des Moines, Iowa 50319-0209

DECISION LETTER

VARIABLE

CODE

PLEASE TYPE OR PRINT IN BLACK INK

�

2. Federal Identification

1. Type of Organization

Corporation

____________________________________

Number (FEIN):

Individual Ownership

S Corporation

_________________________

3. Date Organization Registered:

Partnership

Governmental

___________________

4. Organization Registered In What State:

Limited Liability Partnership (LLP)

Non-profit (501(C)(3) Organization)

5. Current Iowa Unemployment

:__________________________

Account Number, If Assigned

Other ______________________

Limited Liability Company (LLC)

6. LIST NAME OF OWNER, PARTNERS, MEMBERS

RESIDENT ADDRESS

SOCIAL SECURITY

OR CORPORATE OFFICERS:

NUMBER

7. CORPORATION / LLC NAME:

BUSINESS OR TRADE NAME:

(PO BOX)

8. ADDRESS FOR MAILING TAX REPORTS

(STATE)

(ZIP CODE+4)

(CITY OR TOWN)

(COUNTY)

Alternate Telephone Number (+ Area Code)

Business Telephone Number (+ Area Code)

9. Are you required to file the Federal Unemployment Tax

YES

Return (FUTA) for either the current or preceding year?

10. DATE YOU BEGAN EMPLOYING

DATE YOU FIRST PAID

WORKERS IN IOWA

(IF MORE THAN ONE LOCATION, ATTACH SEPARATE LIST -- IF SAME AS NUMBER 8 , CHECK HERE ________ AND SKIP NUMBER 11.

ADDRESS

CITY OR TOWN

STATE

ZIP CODE+4

COUNTY

LOCATION WHERE

11. WORK IS PERFORMED

IN IOWA

**** (MUST SHOW BOTH BUSINESS ACTIVITY AND DETAILED DESCRIPTION) ****

12. NATURE OF BUSINESS ACTIVITY IN IOWA

PRIMARY BUSINESS ACTIVITY

In the space below give details of the primary Iowa business activity (See Reference Guide)

13. FOR EACH OF THE FOLLOWING CALENDAR QUARTERS, ENTER THE GROSS QUARTERLY WAGES PAID IN IOWA

1ST QUARTER

2ND QUARTER

3RD QUARTER

4TH QUARTER

CURRENT YEAR:

____________

PRECEDING YEAR:

____________

IF YOUR COMPANY IS A NON-PROFIT ORGANIZATION EXEMPT FROM INCOME TAX UNDER U.S. INTERNAL REVENUE CODE 26 U.S.C. 501 (C)(3),

PLEASE ATTACH A COPY OF THE LETTER FROM THE IRS CONFIRMING THIS CLASSIFICATION.

Form 60-0126 - Report To Determine Liability - 2006

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