Free Visio-SF2837 New web ver 050509.vsd - Indiana

REPORT TO DETERMINE STATUS
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT Confidential Record Pursuant
10 N. SENATE AVE., INDIANAPOLIS IN 46204-2277 To IC 4-1-6, IC 22-4-19-6

Reset Form
283701-KFI

SF 2837 (R7/4-09)

Office Use Only

Original Report

Transfer

Amended

Pre-assigned

IMPORTANT: Any employing unit which fails to submit any report within 10 days after such request is sent shall be assessed a penalty of not less than $25.00. Reference Indiana Code 22-4-19-10. If you are an employer of agricultural or domestic (household) help, please complete the State forms SF45982 or SF46798. If you are a Single Member Limited Liability Company (SMLLC) or other "disregarded entity", you are required to report under the account of your owner.

1. 2. 3. 4.

Federal Employer ID Number: Legal Name of Employing Unit: Trade Name or DBA:

Indiana County:

Street Address:

P.O. Box:
(If Applicable)

City:

State:

ZIP:

Country:

USA

Canada

Mexico

Other

Business Phone Number:

Business Fax Number:

If you have any other locations in Indiana, please list them in the Remarks section on the reverse side of this form or attach a separate list.

5.

Type of organization (check one):

Individual Corporation

Partnership LLC Corporation

LLC Partnership

Limited Partnership

Federal Government Other (Estate, Trust, Receivership, etc.) Identify (c) Date Payroll Began in Indiana:
(mm-dd-yyyy)

State Government

Local Government

International/Foreign Government Association (b) State: of incorporation:

Sub Chapter S Corporation

Other State Institution

6. 7.

(a) Formation Date of Corp or Partnership:
(mm-dd-yyyy)

Enter the required information for owners, partners, or officers. Please attach additional sheet(s) if needed. Additionally, if an owner is a business entity please enter the employer identification number (EIN) and entity name in the Remarks section on reverse side.
First Name Telephone Number Last Name Telephone Number Last Name

SSN

Title

First Name

SSN

Title

8. 9. 10. 11. 12.

Has your business filed an IRS Form 940 under the Federal ID Number listed above in any state? (NOTE: If you became subject to/liable for/qualified for FUTA in the current or preceeding year and have not yet filed IRS Form 940, answer the question `YES'.) Did you incorporate, purchase, lease or assume all or any part of an existing Indiana business from another business entity? Has your business had a total Indiana payroll of $1,500.00 or more in any calendar quarter during the current or preceding calendar year? (Including salaried officers) Has your business had one or more employees any part of a day, in each of twenty (20) different weeks (not necessarily consecutive) during current or preceding calendar year? 501(c)(3) ­ Did you employ four (4) or more individuals, in any part of a day, in each of twenty (20) different weeks of the current or preceding calendar year?
No Yes

No

Yes

If Yes, you must complete "Section A" on the reverse side.
(Quarter/ Year)

No

Yes

No

Yes

(Last Date of 20th week) (Last Date of 20th week)

No

Yes

If "yes", please submit a copy of IRS exemption letter. If you are an Out of State 501(c)(3), you must meet qualifications aforementioned to be liable in the State of Indiana.

13. 14 a. 14 b.

DOMESTIC ­ (HOUSEHOLD NATURE) Have you paid $1,000.00 or more, cash wages in a calendar quarter to employees? AGRICULTURAL ­ Did you employ ten (10) workers in some part of a day in twenty (20) different weeks during a calendar year?
-OR-

No

Yes

(Quarter/ Year) If Yes, Last Date of 20th week (Quarter/ Year)

No

Yes

AGRICULTURAL ­ Did you have a gross payroll in the amount $20,000.00 in a calendar quarter?

No

Yes

A

PLEASE PRINT USING UPPERCASE LETTERS IN BLACK INK.

A B C 1 2 3

INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N. SENATE AVE., INDIANAPOLIS IN 46204-2277

REPORT TO DETERMINE STATUS
CONFIDENTIAL RECORD PURSUANT TO IC 4-1-6, IC 22-4-19-6

SF 2837 (R7/4-09)

283702-KFI

15. 16. 17.

Primary Business Activity: Are you a PEO/Employee Leasing Company?
No Yes No Yes

Will you be reporting wages under a PEO/Employee Leasing Company?

If Yes, PEO/Employee Leasing Company Account Number

PEO/Employee Leasing Company Name if applicable

Note: If you answered "Yes" to question number 9 on front side, purchased, or continued all or any part of an existing Indiana business, you must complete "Section A" below. Reference Indiana Code 22-4-7-2, Indiana Code 22-4-10-6

SECTION A

If you have questions whether or not this section applies to you, please call (317) 232 ­ 7436.
(Please check one) Lease of Complete Organization Change in Federal ID Number/Change in Entity Corporate Change or Reorganization

Nature of acquisition or change of entity:

Purchase or Merger/Consolidation of COMPLETE Organization Incorporation of Sole Proprietorship Spin-Off of a Subsidiary

Purchase or Merger/Consolidation of a PORTION of Organization

Death of Proprietor

Partnership Change or Reorganization (50% or More Partners Changed) Other (Please explain in Remarks section below)
(mm/dd/yyyy)

Bankruptcy or Other Proceedings

PEO Add Client

Date you purchased, reorganized, incorporated or otherwise took control of the Indiana business:
1. Predecessor/Disposer Indiana SUTA Number: 3. Predecessor/ Disposer Legal Name: 4. Trade Name (or d/b/a): 5. Mailing Address: 2. Predecessor/Disposer Federal ID Number:

City:

State:

ZIP: 6. Disposer Contact Person: First Name: Disposer Contact Person Phone Number:

Phone Number:

Last Name:

I hereby certify that all information contained herein is true, correct and complete to the best of my knowledge and belief.
Print First Name: EMPLOYER'S SIGNATURE and DATE Print First Name: PREPARED BY SIGNATURE and DATE Last Name:

Read & Sign Here

Phone No.

Last Name:

Phone No.

REMARKS

If you are looking for additional information or forms, please go to www.in.gov/dwd/2343.htm or call (317) 232 ­ 7436.