Fillable Q3 2019 Hardship Application 0 (Commonwealth of Massachusetts)

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Q3 2019 Hardship Application 0 (Commonwealth of Massachusetts)

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The Q3 2019 Hardship Application 0 (Commonwealth of Massachusetts) form is 8 pages long and contains:

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  • 16 check-boxes
  • 388 other fields

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
Department of Unemployment Assistance
Employer Medical Assistance Contribution Supplement Unit
Q3 2019 Hardship Waiver Application for Businesses
Financial hardship requires a showing by you that:
(a) your business has acted in good faith in all its relations with the Department, and certifies that it is current
on state taxes and assessments, including, where applicable, the nursing facility user fee assessment; and
(b) you provide evidence of one or more of the following:
(1) your business is unable to pay the EMAC Supplement because of financial hardship and
failure to obtain a hardship waiver is likely to result in substantial reduction in services,
substantial loss of employment, or termination of the employer’s business;
(2) your business has paid an Employer Shared Responsibility Payment and been assessed an
EMAC Supplement in the same calendar year; or
(3) your business experienced a turnover rate of at least 250% over the four quarters
immediately preceding the application.
Business Name and Legal Address
Mailing Address (if different from Legal Address)
Employer Account Number (EAN)
Federal Employer Identification Number (FEIN)
Complete this form if your business is (check all that apply):
Small (<50 headcount)
Seasonal
Staffing company
Billed by the IRS for Employer Shared Responsibility (ESR)
Contract with the state as a human services provider
Other____________________________________________________
Please describe how EMAC Supplement liability has led to a substantial reduction in services, substantial loss
of employment, or termination of the employer’s business.
Are you at risk of terminating your business and/or laying off staff? Yes No
If yes, all financial information and documentation is required.
How many staff members? ____________ What percentage of your workforce? ___________
2
Are you at risk of a substantial reduction in services? Yes No
If yes, all financial information and documentation is required.
Please provide specific details regarding the substantial reduction in services:
Are you a business with a turnover rate of 250% or greater?
Yes No If “Yes,” attach the EMAC Supplement Turnover Rate Worksheet with supporting documentation
and complete the certification in Section VI of this application. You do not need to provide financial information
unless you are also applying because of financial hardship. The Employer Worksheet for Determining Turnover
Rate can be found on Learn about the EMAC Supplement Hardship Waiver webpage.
Has your business been billed by the IRS for Employer Shared Responsibility (ESR)? Yes No
If Yes, provide the amount paid: $________; Date paid: __________ and complete the certification in Section VI
of this application. For supporting documentation, you must provide a copy of ESR bill (IRS letter 226J) and proof
of payment. You are not required to supply financial information.
Section I - Business Identification
Information about your business
Type of Business
Phone Number
Number of Employees
Information about Owners, Partners, Officers, Major Shareholders, etc.
Name
Title
Effective Date
Monthly
Wages
Percentage of
Ownership
Section II - Assets
Cash on Hand
Total $
Bank Accounts (General Operating, Payroll, Savings, Certificate of Deposit, etc.)
Name of Institution
Account Number
Type of Account
Balance
Total $
3
Bank Credit Available (Line of Credit, Credit Cards, etc.)
Name of Issuer
Account Number
Credit Limit
Amount
Owed
Credit Available
Total $
Real Estate (including Investment Property, Unimproved Land, Buildings, Lots, Commercial Property, etc.)
Description
Address
Current Market
Value
Amount
Owed
Equity in Property
Total $
Vehicle(s) (excluding Leased Vehicles)
Description
Make
Year
Tag
Number
Current
Market Value
Amount
Owed
Equity in Vehicle
Total $
4
Accounts / Notes Receivable
Name
Status
Amount
Due
Credit Available
Total $
Loans from Business to Proprietor, Partner, Officers, Shareholders or Others
Name
Relationship
Payoff Date
Status
Amount Due
Total $
Machinery and Equipment (including Furniture, Fixtures, Business Machines, etc.)
Description
Current Market
Value
Amount
Owed
Equity in Machinery
and Equipment
Total $
5
Merchandise Inventory (Goods held for Sale and/or Raw Materials used in Manufacture, Fabrication or
Production)
Description
Current Market
Value
Amount
Owed
Equity in
Merchandise
Total $
Securities (Stocks, Bonds, Mutual Funds, Government Securities, Money Market Fund, etc.)
Type
Issuer
Description
Current or Appraised Value
Total $
Other Assets
Description
Current or Appraised
Value
Description
Current or Appraised Value
Notes Receivable
Patents or Copyrights
Timber, Mineral or
Drilling Rights
Other Assets:
Collectables, Antiques
or Artwork
Judgments or
Settlements Receivable
Total $
6
Section III - Liabilities
Liabilities (Do not include any Mortgages or Vehicle Loans)
Description
Total Amount Owed
Description
Total Amount Owed
Notes Payable
Past Due Federal Taxes
Loans Payable
Past Due State Taxes
Vehicle Lease(s)
Past Due Other Taxes
Bank Revolving Credit
Equipment Leases
Judgments Payable
Other Liabilities:
Accounts Payable
Total $
Section IV - Net Worth Calculation
Category Totals from Sections II and III
Cash on Hand
$
Bank Accounts
$
Bank Credit Available
$
Real Estate
$
Vehicles
$
Accounts/Notes Receivable
$
Loans from Business to Proprietor, Partners, Officers, Shareholders or Others
$
Machinery and Equipment
$
Merchandise Inventory
$
Securities
$
Other Assets
$
Total Assets
$
Liabilities
$
Net Worth (“Total Assets” minus “Liabilities”)
$
7
Section V – Income and Expense Analysis
Income
Amount
Expenses
Amount
Gross Receipts from
Sales, Services, etc.
$
Materials Purchased
$
Gross Rental Income
$
Net Wages and Salaries
$
Interest Income
$
Rent or Mortgage Expenses
$
Dividends and Capital
Gain Distribution
$
Installments and Lease Payment
$
Royalty Income
$
Supplies and Office Expenses
$
Commission
$
Utilities
$
Other Income (specify)
$
Transportation Expenses
$
$
Repairs and Maintenance
$
$
Insurance
$
$
Current Taxes
$
$
Bad Debts
$
$
Travel and Entertainment
$
$
Advertising
$
$
Other Expenses (specify)
$
$
$
$
$
Total Income
$
Total Expenses
$
Net Income (“Total Income” minus “Total Expenses”)
Total $
*The above Income and Expense Analysis should be reflective of the time period from Q4 2018 through Q3
2019. The information included on your Income and Expense Analysis should be supported by your Profit and
Loss statement.
8
Section VI - Certification
Is this business in compliance and current on state taxes and assessments, including, where applicable, the
nursing facility user fee assessment?
Yes No If “No,” list tax type(s) and period(s) that are not current:
Is this business currently in compliance with all filing and payment requirements with Massachusetts Department
of Unemployment Assistance?
Yes No If “No,” explain why:
Is a foreclosure proceeding pending on any real estate, equipment or other property that this business owns or
has an interest in?
Yes No
Is another party holding any assets on behalf of this business?
Yes No If “Yes,” identify:
Is this business currently under bankruptcy court jurisdiction?
Yes No If “Yes,” Bankruptcy Case Number:
I/We have examined this Hardship Waiver Application for Businesses and hereby affirm under the pains and
penalties of perjury it is true, correct and complete. I/we understand that failure to answer all questions on this
form completely and accurately will result in the rejection of any requested relief.
Taxpayer Name _____________________________________ Title ____________________________
Taxpayer Signature __________________________________ Date____________________________
Taxpayer Name _____________________________________ Title ___________________________
Taxpayer Signature __________________________________ Date___________________________
P.O.A. Name _____________________________________
P.O.A. Signature __________________________________ Date____________________________
Send this completed, signed application and all attachments by email to EMAChardshipwaiver@mass.gov by
5:00 p.m. on October 11, 2019. The email subject line should include the EAN and company name. All questions
must be answered; if a question does not apply, enter “N/A”. Your determination will be issued to you by email,
using the same address that submitted the application on behalf of your company.
Please note that late applications will not be reviewed.
The Director may revoke a hardship waiver if he finds that an employer or authorized representative submitted
false information on the application. The waiver shall be revoked upon notice to the employer, and the employer
shall be liable for the amount waived pursuant to the hardship waiver, plus applicable penalties and interest.
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9
Remember to include all applicable attachments from the list below.
If you would like an attorney, CPA, or authorized agent to represent you, make sure the current tax year is
specified on the Power of Attorney authorization.
For businesses applying because they are unable to pay the EMAC Supplement due to financial hardship and
failure to obtain a hardship waiver is likely to result in substantial reduction in services, substantial loss of
employment, or termination of the employer’s business, the following supporting documentation is required:
A current Profit and Loss statement covering at least the most recent 12-month period (October 2018-
September 2019).
Copies of the six most recent bank statements for each business account and copies of the three most
recent statements for each investment account.
Copies of the most recent statement of outstanding notes receivable.
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages),
monthly payments, loan payoffs, and balances.
Copies of reimbursements from the state.
For those employers applying because they have paid ESR, the following documents below are required:
Proof of payment to the IRS for ESR bill.
Copy of ESR bill (IRS letter 226J) if applicable.
For employers applying because they have experienced a 250% turnover rate, the documents below are
required:
Turnover rate worksheet
Weekly payroll record for the first week of 2018Q4
Weekly payroll record for the first week of 2019Q1
Weekly payroll record for the first week of 2019Q2
Weekly payroll record for the first week of 2019Q3
Weekly payroll record for the last week of 2019Q3
NOTE: If a section of the hardship waiver does not apply to you, please write ‘N/A’. For all
applicable sections, please fill in completely and do not simply write ‘see attached’. Applications
that include this language may impede your chances of being approved.
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Q3 2019 Hardship Application 0 (Commonwealth of Massachusetts)

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Completed 25 July 2020

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