Fillable Unemployment Insurance (UI) (Texas Association of Nonprofit Organizations)

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Unemployment Insurance (UI) (Texas Association of Nonprofit Organizations)

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  • 29 check-boxes
  • 55 other fields

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Unemployment Insurance (UI)
Application Form
Organization Profile
Organization
Name
Physical
Address
City
State
Zip
Contact Title Website
Telephone Fax Email
Operations Profile
Type of Entity
501c3 Government
Date Est. When is your fiscal year?
Description of Applicant’s Operation
Current UI Funding
Method:
Paying State Unemployment Tax
Reimbursing (self-insured)
State
Acct. No.
FEIN
If taxpaying: If reimbursing:
Have you paid unemployment taxes for at
least two years?
Yes No
Check current management method:
Internal Staff Third Part Administrator Group Program
Are you currently in good standing with the
state?
Yes No
Current
administrator/program
(if applicable):
Employment Profile Please attach an additional sheet of paper, as needed, to more fully answer the following questions:
Number of Full-time Employees Number of Part-time Employees Number of W-2s from Prior Years
1. Do you anticipate any loss or reduction in overall revenue within your organization that will
result in layoffs, and/or reduction in employees’ hours or wages within the next 12 months?
Yes
No
If yes, please explain and include estimated number
of affected employees and date(s) of action.
2. Do you anticipate any elimination or reduction of any revenue source(s) within your
organization that will result in layoffs, and/or reduction in employees’ hours or wages within
the next 12 months?
Yes
No
If yes, what source and provide explanation (include
number of affected employees and date(s) of action).
3. Do you anticipate any restructuring within your organization that will result in layoffs, and/or
reduction in employees’ hours or wages within the next 12 months?
Yes
No
If yes, please explain and include estimated number
of affected employees and date(s) of action.
4. Have you experienced any layoffs/staff reductions, other than regular seasonal during the last 12
months?
Yes
No
If yes, please explain. Include number of affected
employees and the dates on which layoffs or staff
reductions took place.
5. Do you anticipate an increase in the hiring of employees who will be affected by seasonal layoffs
over the next 12 months?
Yes
No
If yes, please explain. Include number of employees
and date(s) of action.
PAGE 1 OF 2
Unemployment Insurance
Application Form cont’d
Employment Profile cont’d
6. Are you currently or have you, in the past 12 months, had employees whose wages are exempt
from unemployment?
Yes
No
If yes, please explain. Include number of exempt
employees and their term of employment.
7. How many of your employees are seasonal and when is their
seasonal term?
8. How many of your employees are employed in a Head Start
program and when is their term of employment?
9. Please enter the following estimates:
10. Approximately how many
claims do you have annually?
Year Gross payroll
UI Benefit Charges
(claims paid)
UI Tax Rate
(if applicable)
Annual Budget
2010
2011
11. Approximately how many of
those claims are protested?
2012
2013 (est.)
Funding Profile
1. What percentage of your annual payroll is attributable to the following funding
sources:
2. Are there any upcoming funding issues, not previously
mentioned on this application, specific to your organization
or your sector that might affect your employment levels?
Federal
Fundraising or
Operations
State
Grants/Other
(Please specify.)
City/County
How did you hear about us?
Please specify (such as Google, Webinar, etc.):
TANO Insurance Agency Website/Search Engine
Advertisement Event Other
Signature
The information provided on this application form has been confirmed by all necessary parties within this organization to be true, accurate, and
complete to the best of our knowledge. We acknowledge that any misrepresentation will result in immediate cancellation of any service or
coverage pursuant to the terms of this product for which this application is submitted.
Signature (No electronic signatures, please.)
Name
Date
Title
Fax back to: (312) 239-8368
PAGE 2 OF 2
Questions? Call (800) 526-4352, ext. 8394.
All employers: Provide copies of your 3rd quarter 2012 to most recent wage reports and the information listed below found on
https://services.twc.state.tx.us/
1. Select "Business & Employers" 3. Logon to your account
2. Select "Access your tax account info" from the 4. Select the "Report filing (C3)" tab
options on the left side of the screen 5. Select "Chargeback history"
Taxpaying employers: Submit a copy of your 2013 C-22 “Tax Rate Notice” form
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Unemployment Insurance (UI) (Texas Association of Nonprofit Organizations)

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Completed 31 January 2021

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