Free lb0443R4.08.pmd - Tennessee

TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY EMPLOYER SERVICES (STATUS/RATES) 220 FRENCH LANDING DRIVE NASHVILLE TN 37243 (615)741-2486 Fax (615)741-7214 1. Federal No. ___ ___ ___ ___ ___ ___ ___ ___ ___ Name _________________________________________ _________________________________________ Address _________________________________________ _________________________________________ _________________________________________ E-Mail Address ____________________________________

REPORT TO DETERMINE STATUS
STATE AND LOCAL GOVERNMENT
OFFICIAL USE ONLY M. No. SIC

Tennessee ID#

County

Area

Liab. Org.

First Employment

Date Liable

Rate

Comp Year

NAICS

M-NAICS

M-SIC

Previous No.

ROC

AUX-SIC

VERIFIED

Phone _____________________________________ Fax _______________________________________

Note: Attach copy of Public Act creating your governmental organization.
2. PHYSICAL ADDRESS in Tennessee if different from above: _______________________________________________________

________________________________________________________________________________________________________

3. (a) Type of governmental entity:

State Government

Local Government

(b) List below all State or Local governmental agencies or departments that will report under this account number. Agency or Department Address County Nature of Service Number of Employees

Attach list if additional space is needed. (c) Name and Title of three (3) principal officers or officials: (1) Name ________________________ (1) Title _________________________ (2) Name ________________________ (2) Title __________________________ (3) Name ________________________ (3) Title __________________________ Phone Number _____________________

4. Name of person responsible for payroll records ______________________________ 5. Date your governmental entity first had employees in Tennessee _____/_____/_____

6. Does your governmental entity elect to reimburse the Department of Labor and Workforce Development for benefits paid in lieu of paying premiums? YES NO If answer is "YES," complete Reimbursement Election on page 2 of this form. (See Page 2)

NOTE: Reimbursing employers are liable for all benefits based on wages paid by them including overpayments due to administrative errors or improper employer reporting.
THIS REPORT MUST BE SIGNED BY AN AUTHORIZED OFFICIAL.
DATE SIGNATURE TITLE

LB-0443 (Rev. 04-08)

ELECTION TO BECOME A REIMBURSING EMPLOYER

Date _____/_____/_____

Pursuant to the provisions of Section 50-7-403(h) of the Tennessee Employment Security Law, the undersigned eligible employer elects to reimburse the Tennessee Department of Labor and Workforce Development for all unemployment insurance benefits (including the amount of extended benefits) charged to this legal entity during the effective period of election. This employer elects to reimburse the Department of Labor and Workforce Development for benefits charged by one of the two methods indicated below:

1. The Department shall bill the employer on a monthly basis for the full amount of regular benefits plus one-half of extended benefits paid attributable to service in the employ of the employer. The employer shall make full payment of the billed amount within thirty (30) days from the date the bill was mailed to the employer, unless the employer has filed an application for a review and redetermination of such bill. If an application for a review and redetermination has been filed, the employer must pay the bill in full within fifteen (15) days of the final determination of this issue by the Department of Labor and Workforce Development.

or
2. The employer shall on a quarterly basis pay a percentage of its total payroll for the immediately preceding calendar year. The percentage will be determined by the Department based on the employer's average unemployment benefit cost during the preceding calendar year. (The Department will determine the percentage if the employer did not pay wages in the preceding calendar year.) At the end of the calendar year, the Department will determine whether the total payments are less than or in excess of benefits chargeable to the employer during the calendar year. If the payments are insufficient, the employer will be billed for the unpaid balance. If the payments are in excess of benefit charges, the Department may, at its discretion, refund all or part of the excess or may retain all or part as payment against charges expected to be incurred in the next calendar year. This agreement is effective for a minimum of one complete taxable year. Any request to terminate this agreement and become a premium-paying employer must be filed in writing with the administrator of the Employment Security Division within thirty (30) days prior to the end of the then current taxable year. (All taxable years end on June 30th.)

Agency __________________________________ By ______________________________________ Title _____________________________________

LB-0443 (Rev. 04-08)

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