COMPANY INFORMATION - Include physical address of work performed. (Enter either 6380 or 6440 Aviation Way.)
ADDITIONAL INFORMATION (Required.)
WITHHOLDING FOR WORKPLACE AT 6380 AVIATION WAY
Corporation
Non-Profit
S-Corp
Estate/Trust
LLC
Sole proprietor/LLC
Partnership
Fiscal Year End:
# of Employees Working in JEDD1 Start Date:
Please note that the WC JEDD I does not have any residents living
in the WC JEDD I. Therefore, there are no courtesy withholdings.
Type of Product/Service:
Federal ID #:
Federal ID #:
(FID used for submitting withholdings)
(FID used for reporting net profit/loss)
Name:
D/B/A:
WC JEDD I Location:
Mailing
Address: (for tax forms, if different from above.)
Contact Person
Telephone
Number:
SSN:
(Required if sole proprietor)
*
Please note that your Federal ID will serve
as your WC JEDD I account number for
withholding and net profit accounts.
Quarterly Withholding
Monthly Withholding (over $200/mo
.)
Semi-Monthly Withholding
Payroll Company:
Yes
No This company replaces a company previously registered:
(Name)
FID (Net Profit): FID
(Withholding):
Yes No This company is a small employer. (under $500,000 in gross revenue during previous year.)
Yes
No This company is a contractor. (Attach list of subcontractors.) Contract Amount: $
Yes
No This company leases employees. (Name of leasing company):
Name/Address
of Corporate Officers (Attach list.):
If your payroll provider requires verification of your Fairfield account number, fax them a copy of this form to verify Fairfield uses your FID as our account number.
(Print Name) (Title) (Phone Number) (E-Mail)
_ I hereby verify that the above information is true and correct.
(Signature)
(For work performed at 6380 and 6440 Aviation Way, West Chester, Ohio)
REASON FOR ACCOUNT REGISTRATION
TYPE OF BUSIN
ESS
WEST CHESTER JEDD I - BUSINESS REGISTRATION
WITHHOLDING FOR
WORKPLACE AT 6440 AVIATION WAY
NET PROFIT for business conducted at 6440 or 6380 Aviation Way
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signature
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