RETURN TO:
TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER ACCOUNTS/EMPLOYER SERVICES
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE, TN 37243
(615) 741-2486 FAX (615) 741-7214
5. Name of person responsible for payroll records _______________________________________ Phone Number _______________________
1A. Enter Professional Employer Organization (PEO) Information
PEO State No. ___ ___ ___ ___ - ___ ___ ___ ___
PEO Name ____________________________________________
1B. Enter Client Company Information
Client’s Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___
Client’s Employer Name ____________________________________
____________________________________
Client’s Trade Name ____________________________________
____________________________________
Client’s Mailing Address ____________________________________
____________________________________
2.
Client’s PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:
______________________________________________________________
______________________________________________________________
Client’s fax number: _________________________
Client’s company phone: _________________________
Client’s email address: ______________________________________
FOR CLIENTS OF A PROFESSIONAL EMPLOYER ORGANIZATION
Client’s business website: _____________________________________
INDIVIDUAL __________________________________________________________________________
PARTNERSHIP __________________________________________________________________________
CORPORATION __________________________________________________________________________
LIMITED LIABILITY COMPANY __________________________________________________________________________
LIMITED PARTNERSHIP __________________________________________________________________________
OTHER __________________________________________________________________________
4. Name of Client Company’s Partners, Corporate Officers, Limited Liability Company
Members and Managers (if Board Managed), General Partners
(Attach separate sheet if necessary.)
Social Security
Number
3. CHECK (X) FORM OF ORGANIZATION
OF CLIENT COMPANY
LB-0910 (Rev. 02-15) RDA 1559
NOTE: If a Limited Liability Company, are you treated by IRS as a(n)
Individual Proprietorship
Partnership or as a
Corporation?
9. HOUSEHOLD EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Has your client had or does your client expect to have a $1,000 quarterly payroll for domestic services? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________ YEAR _____________
6. A. Number of workers your client has employed (will employ) in TN ____________ D. Is your client presently reporting for U.I. purposes in another state?
YES NO If YES, which state? ___________________
E. If your client is a corporation or LLC, provide formation information.
Date ______________ State _____ Control No. ____________
B. Date your client first employed (will employ) a worker in TN ________________
C.Date your client first paid (will pay) a worker in Tennessee _________________
7. NONPROFIT EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Is your client organization exempt from Federal Income Taxes under Section 501(c)(3) of the IRS Code? YES
NO
If YES, attach a copy of letter of exemption.
B. Has your client employed or expects to employ four (4) or more individuals in Tennessee for any portion of a day within twenty (20) different weeks
in a calendar year? YES NO
If answer is YES, give month and year of the twentieth week of the first year this occurred. MONTH ________________ YEAR __________
OFFICIAL USE ONLY
Tennessee ID Number M. No. County Alt Zip
Verified
Liab. Org.
Date LiableFirst Employment
Rates
10. AGRICULTURAL EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Has your client employed or does your client expect to employ at least ten or more workers in some part of a day in twenty different weeks during a
calendar year? YES NO
If YES, give earliest month and year this occurred (will occur). MONTH ________________ YEAR ___________
B. Has your client had or does your client expect to have a quarterly payroll of $20,000 or more? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________ YEAR ____________
PLEASE COMPLETE PAGE 2.
Comp Year NAICS M-NAICS
____________________________________________________________
8. REGULAR BUSINESS EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Has your client employed or does your client expect to employ at least one worker in twenty different calendar weeks during a calendar year?
YES NO If YES, give earliest month and year the twentieth week occurred (will occur). MONTH ______________ YEAR ________
B. Has your client had or does your client expect to have a quarterly payroll of $1,500 or more? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________ YEAR ________
____________________________________________________________
Client’s Signature ___________________________________ Title ______________________________ Date ______________
C. Is all activity performed on a farm? YES NO If NO, what percentage is? ________ Please explain in 11A on page 2.
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
APPLICATION FOR CLIENT NUMBER
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