Free LB0441R8.07NewAddress.pmd - Tennessee

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT RETURN TO: EMPLOYER SERVICES TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT 220 FRENCH LANDING DRIVE NASHVILLE TN 37243 (615) 741-2486 FAX (615) 741-7214

REPORT TO DETERMINE STATUS APPLICATION FOR EMPLOYER NUMBER
Tennessee ID# OFFICIAL USE ONLY M. No. SIC County Area

1. Enter Federal Number, Business Name and Address Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___

Liab. Org.

First Employment

Date Liable

Rate

Employer Name _______________________________________ _______________________________________ _______________________________________ _______________________________________ Mailing Address _______________________________________ Trade Name _______________________________________ _______________________________________ PHYSICAL BUSINESS ADDRESS in Tennessee if different from above: _______________________________________________________ _______________________________________________________
2. Is your organization a Staff Leasing Company? YES NO
Comp Year NAICS M-NAICS M-SIC

Previous No.

ROC

AUX-SIC

VERIFIED

PHONE: ( _______ ) ___________________ FAX: ( _______ ) ______________________ E-MAIL ADDRESS: _____________________________
If Yes, Tennessee license number __________________ Social Security Number Residential Address and Phone

3. CHECK (X) FORM OF ORGANIZATION

Is your organization a client of a Staff Leasing Company? YES NO 4. Name of Owner, Partners, Corporate Officers Limited Liability Company Members and Managers (If Board Managed), General Partners (Attach separate sheet if necessary)

INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY LIMITED PARTNERSHIP OTHER
NOTE: If a Limited Liabilty Company, are you treated by IRS as a(n) Individual Proprietorship Partnership or as a Corporation

5. Name of person responsible for payroll records _____________________________________ 6. A. Number of workers you have employed (will employ) in TN __________________

Phone Number _______________________

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.

/ / B. Date you first employed (will employ) a worker in TN _______________________ / / C. Date you first paid (will pay) a worker in Tennessee _______________________

/ / Date _______________ State ____ ID No. _______________

7. 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 ______________________ B. Have you had or do you expect to have a quarterly payroll of $1,500 or more? 8. HOUSEHOLD EMPLOYMENT YES NO YEAR ____________________ NO YEAR _______________ If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________ A. Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? YES If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________ YEAR _______________

(SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID)

9. 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 ______________________ YES NO YEAR _______________ YEAR ______________ B. Have you had or do you expect to have a quarterly payroll of $20,000 or more?

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________

If you answer Yes to any one of the questions 6D, 7, 8, 9, or 10F, you are liable for unemployment insurance premiums based on the first $7,000 paid each employee per year. Have you previously had an account with this department? YES NO Account Number ____________________________

/ / Signature ____________________________________ Title _________________________ Date ________________________ Must be owner, partner, authorized limited liability company member or manager, or officer of the corporation.
PLEASE COMPLETE PAGE 2. FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.
LB-0441 (Rev 8/07) RDA N/A

10. (A) Name and Address of predecessor employer

_______________________________________________________ _______________________________________________________ _______________________________________________________ (C) Date of acquisition _____/_____/_____ NO NO If No, what percentage did you acquire? _____

(B) Account Number of predecessor employer _____________________ (D) Did you acquire all of your predecessor's business in Tennessee? YES (E) Did your predecessor continue in business in Tennessee? YES

(F) Tennessee Employment Security Law provides for the mandatory transfer of an employer's benefit and premium experience whenever there is any common ownership, management or control between the predecessor and successor employers. Did any owner or manager of this company have an ownership interest in or participate in the management or control of the business acquired? YES NO If "YES," please explain: __________________________________________________________________________________ Per TCA 50-7-403(b)(2)(C)(ii) "Common ownership, management or control" includes any individual who has at least a 10% ownership interest in - or who participates in the management or control of - the predecessor's trade or business and has a relative with a 10% ownership interest in or who participates in the management or control of - the successor's trade or business. Does anyone who had a 10% or more ownership interest in the previous company - or who participated in its management or control - have a relative with a 10% or more interest in this company or who participates in its management or control? YES NO If "YES," please explain: __________________________________________________________________

If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483, Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which the acquisition occurred. 11. Enter below the amount of total payroll for each quarter in which you have had or expect to have employment. YEAR JAN-MAR APR-JUNE JUL-SEPT OCT-DEC YEAR JAN-MAR APR-JUNE JUL-SEPT OCT-DEC

NOTE: If your organization is exempt from Federal Income Taxes under Section 501(C) (3) of the IRS Code, attach a copy of letter of exemption.

Non-profit public, and/or governmental organizations are not exempt from state unemployment insurance, unless certain requirements are met. If you are unsure about your present or future unemployment insurance status, please contact us for assistance at (615)741-2486. 12. FAILURE TO PROPERLY COMPLETE THIS SECTION WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE. Briefly describe the major business activity of the account to be covered, listing any products produced or sold, or service provided. Be as descriptive as possible. _____________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ In what Tennessee County is your company located? ________________________________________________________
(If account covers sales reps or other personnel working from home, list county of residence. If county is unknown, list city of residence.)

For the work location covered by this application, is the main activity to: (Check one) Supply products and services to the general public or other companies Support other locations of your company (if you check this, please specify below) HEADQUARTERS (e.g. : Corporate or regional management offices) ADMINISTRATIVE, OTHER THAN HEADQUARTERS (e.g.: data processing, public relations) RESEARCH (e.g.: R & D, product testing, laboratory) STORAGE (e.g.: warehouse, distribution center, equipment yard) OTHER (please describe) (e.g.: Repair shop, security office, maintenance, employee recreation facility)

Please check the box describing your company's major business activity:
Agriculture, Forestry, Fishing and Hunting Mining Utilities Construction Manufacturing Wholesale Trade Retail Trade Transportation and Warehousing Information Finance and Insurance
LB-0441 (Rev. 8/07)

Real Estate and Rental and Leasing Professional, Scientific, Technical Services Management of Companies and Enterprises Administrative and Support and Waste Management and Remediation Services Educational Services Health Care and Social Assistance Arts, Entertainment and Recreation Accommodation and Food Services Other Services (except Public Administration) Public Administration

INFORMATION FOR COMPLETING STATUS APPLICATION
Enclosed is a Report to Determine Status/Application for Employer Number. The Tennessee Employment Security Law and Regulations requires each employing unit in Tennessee to file this report with the Department of Labor and Workforce Development for the purpose of determining status. If you answer "Yes" to question 6(d) or any one of the questions in items 7, 8 or 9 on the status application, you are liable for unemployment insurance coverage with this department. Please complete and submit the enclosed form as soon as you have paid wages for services performed in Tennessee. The requirements for liability are:

REGULAR BUSINESS EMPLOYERS
Items 7 A and B on the status application do not pertain to farm or household employees. Item 7A. During some part of a day in each of twenty calendar weeks of a calendar year, did you employ or do you expect to employ one or more persons? (The weeks need not be consecutive and both full and part-time workers are counted.)

OR Item 7B. Have you paid or do you expect to pay wages of $1,500 or more in any calendar quarter?

HOUSEHOLD EMPLOYERS
Item 8. Did you have or do you expect to have a calendar quarter in which you paid household employee(s) $1,000 or more in cash wages? If so, you are liable for all wages paid during that year and the following calendar year.

AGRICULTURAL EMPLOYERS
Item 9A. During some part of a day in each of twenty weeks of a calendar year did you employ or do you expect to employ ten or more persons? (The weeks need not be consecutive and both full and part-time workers are counted.)

OR Item 9B. Have you paid or do you expect to pay wages of $20,000 or more in any calendar quarter?

Leave the space under Item 1 for Federal Number blank if you have not yet been assigned a FEIN (Federal Employer Identification Number). You will receive a letter asking for this number after we establish your state account. Return the letter with your FEIN when you receive the number from the Internal Revenue Service. If you are completing quarterly reports and/or the Application for Transfer of Experience Rating (LB-0483), please return them in the same envelope with this application. DO NOT write in the box titled State Account Number if you are submitting quarterly Premium (LB-0456) and Wage (LB-0851) Reports along with this application. Your new number will be recorded here when assigned. Anyone who is paid for personal services by a corporation is considered to be an employee of the corporation even if that person is an officer and/or owns stock in the corporation. NOTE: PLEASE BE SURE TO SIGN YOUR STATUS APPLICATION at the bottom and include the appropriate information. Also, complete both pages of your Status Application form.

Failure to complete both pages of the application or to provide sufficient information upon which to correctly classify the industry code will result in the highest new employer rate being assigned.
(Revised 8/07)

Mail To: Employer Services TN Dept of Labor and Workforce Development 220 French Landing Drive Nashville TN 37243

PREMIUM RATE INFORMATION
New employers in Tennessee are initially subject to a "new employer" rate until their account has been subject to premiums and chargeable with benefits for thirty-six consecutive months ending on the computation date (December 31, of each year). They then become eligible, beginning on the next July 1, for a premium rate based on their individual reserve experience. New employer rates are determined separately for each major industry group based on the combined reserve experience of each industry group as a whole. New employer rates for each industry, like individual experience rates to eligible employers, are redetermined each year effective July 1. Presently, all industries, except construction, mining, and manufacturing sectors 31 and 32, have a new employer rate of 2.7%. The new employer rates for construction, mining, and manufacturing are listed below. Rate Year Construction Mining Manufacturing

July `02 - June `03 July `03 - June `04

7.0% 7.5%

10.0% 10.0%

6.5% 7.5%

As of July 1, 2004, new employer premium rates are based on the combined reserve experience of the North American Industry Classification System (NAICS) sector of which the employer is a part. Under NAICS, manufacturing is split into three separate sectors. NAICS-based new employer rates are shown on the table below. Rate Year Construction Mining Sector 31 July `04 - June `05 July `05 - June `06 July `06 - June `07 July `07 - June `08 July `08 - June `09 06.0% 06.0% 06.0% 05.0% 05.0% 07.0% 08.0% 07.5% 06.5% 06.0% 6.0% 6.0% 06.0% 06.0% 05.5% Manufacturing Sector 32 2.7% 2.7% 02.7% 02.7% 0 2.7% Sector 33 6.5% 6.0% 06.0% 06.0% 06.0%

NAICS Manufacturing Sector 31 includes food, beverage, and tobacco products, as well as textiles, leather, and apparel products. NAICS Manufacturing Sector 32 includes wood products, paper products, printing and related support activities, petroleum and coal products, chemical manufacturing, plastics and rubber products, and nonmetallic mineral products. NAICS Manufacturing Sector 33 includes metal products, machinery, computer and electronic products, electrical equipment, appliances, transportation equipment, and furniture manufacturing.
(Revised 8/07)

Taxable wages are the first $7,000 of gross wages paid to each employee per year.