TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
REPORT TO DETERMINE STATUS
APPLICATION FOR EMPLOYER NUMBER
1. Enter Federal Number, Business Name and Address
Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___
Employer Name ________________________________________
________________________________________
Tra de Nam e ________________________________________
________________________________________
Mailing Address ________________________________________
________________________________________
6. Name of person responsible for payroll records _____________________________________ Phone Number _______________________
FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE. LB-0441
(Rev. 09)
RDA 1559
7. A. Number of workers you have employed (will employ) in TN _________________ D. Are you presently reporting for U.I. purposes in another state?
YES NO If YES, which state? __________________
E. If a corporation or LLC, provide formation information.
Date ______________ State _____ Control No. ______________
3. Is your organization a Professional Employer Organization (PEO)? YES NO If Y
ES, Tennessee license number ________________
Is your organization a client of a Professional Employer Organization (PEO)? YES NO
If YES, STOP. Please complete LB-0910, Application for Client Number.
PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:
______________________________________________________
______________________________________________________
B. Date you first employed (will employ) a worker in TN __________________
C. Date you first paid (will pay) a worker in Tennessee __________________
RETURN TO: TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
EMPLOYER ACCOUNTS/EMPLOYER SERVICES
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE TN 37243-1002
(615) 741-2486 FAX (615) 741-7214
Fax:___________________Phone:____________________
Business Website:_______________________________________
NOTE:If corporation is a nonprofit, exempt from Federal Income Taxes under Section 501(C)(3) of the IRS Code, STOP.
Please complete LB-0444, Report to Determine Status, Nonprofit Organization.
4. CHECK (X) FORM OF ORGANIZATION
NOTE:If a Limited Liability Company, are you treated by IRS as a(n)
Individual Proprietorship
Partnership or as a
Corporation?
8. REGULAR BUSINESS EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you 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. Have you had or do you 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 ______________
10. AGRICULTURAL EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you employed or do you 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. Have you had or do you expect to have a quar terly payroll of $20,000 or more? YES NO
If YES, give earliest quarter and year this occurred (will occur). QUARTER ______________________ YEAR ____________
C. Is all activity performed on a farm? YES NO If NO, what percentage is? __________ Please explain in 13A on page 2.
5. Name of Owner, Partners, Corporate Officers, Limited Liability Company
Members and Managers (If Board Managed), General Partners
(Attach separate sheet if necessary.)
Social Security Number
INDIVIDUAL _________________________________________________________________________
PARTNERSHIP _________________________________________________________________________
CORPORATION _________________________________________________________________________
LIMITED LIABILITY COMPANY _________________________________________________________________________
LIMITED PARTNERSHIP _________________________________________________________________________
OTHER _________________________________________________________________________
Email Address: ______________________________________
OFFICIAL USE ONLY
PLEASE COMPLETE PAGE 2.
Must be signed by owner, partner, authorized limited liability company member or manager, or officer of the corporation.
Signature ________________________________________ Title ______________________________________ Date ______________________
9. HOUSEHOLD EMPLOYMENT
(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)
A. Have you had or do you 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 _____________
2. Have you previously had an account with this department? YES
NO
If YES, Account Number _______________________
Ten n e s see ID Number M. No . County Alt Zip
Liab. Org. Date LiableFirst Employment
Ver ifiedComp Year NAICS M-NAICS
Previous No. Rate
____________________________________
____________________________________
STOP
STOP
