Form LS671 "Professional Employer Organization Request for Exemption" - New York

What Is Form LS671?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LS671 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form LS671 "Professional Employer Organization Request for Exemption" - New York

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Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, NY 12240
Professional Employer Organization
Request for Exemption
A. Qualification for Exemption
A PEO can request “Exempt” status if:
It does not maintain an office in New York State
It does not engage in direct solicitation of business in New York State
It does not have more than 25 worksite employees in New York State
It is licensed to do business as a PEO in another state that has the same or greater requirements as New
York State
If all of the above requirements are met, complete this form. If any of the requirements are not met, the PEO
must complete form LS 665, Request for Registration.
B. Type of Request (check one)
Initial
Renewal
C. General Information
1a. Name of Professional Employer Organization:
b. Additional names, if any, under which the PEO currently conducts business.
2.
Type of business organization (mark one):
Corporation
Sole Proprietorship
Partnership
Limited Liability Company
Limited Liability Partnership
3.
Federal Employer Identification Number (FEIN): __ __ - __ __ __ __ __ __ __
4.
4a. Complete physical address of Principal Administrative
Office:
4b.
Mailing address, if different:
4c. Telephone, fax, and email address of Principal Administrative Office:
Telephone:
Fax:
Email:
5.
States in which the PEO is licensed or registered as a PEO, its license or registration number, and the State
Agency that issued it:
6.
Fiscal year starts
and ends
LS 671 (09/18)
Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, NY 12240
Professional Employer Organization
Request for Exemption
A. Qualification for Exemption
A PEO can request “Exempt” status if:
It does not maintain an office in New York State
It does not engage in direct solicitation of business in New York State
It does not have more than 25 worksite employees in New York State
It is licensed to do business as a PEO in another state that has the same or greater requirements as New
York State
If all of the above requirements are met, complete this form. If any of the requirements are not met, the PEO
must complete form LS 665, Request for Registration.
B. Type of Request (check one)
Initial
Renewal
C. General Information
1a. Name of Professional Employer Organization:
b. Additional names, if any, under which the PEO currently conducts business.
2.
Type of business organization (mark one):
Corporation
Sole Proprietorship
Partnership
Limited Liability Company
Limited Liability Partnership
3.
Federal Employer Identification Number (FEIN): __ __ - __ __ __ __ __ __ __
4.
4a. Complete physical address of Principal Administrative
Office:
4b.
Mailing address, if different:
4c. Telephone, fax, and email address of Principal Administrative Office:
Telephone:
Fax:
Email:
5.
States in which the PEO is licensed or registered as a PEO, its license or registration number, and the State
Agency that issued it:
6.
Fiscal year starts
and ends
LS 671 (09/18)
D. Submission Instructions
For any questions, email
PEOInfo.LS@labor.ny.gov
or call (518) 457-1942.
The initial application for exemption must be submitted prior to placement of worksite employees in New York
State. A renewal application for exemption must be submitted no later than 180 days after the end of the PEO’s
fiscal year.
Make sure you have marked on the first page whether this is an initial or renewal request.
With an initial request, submit a copy of the corporate filing receipt and/or authorization to do business in New
York State from the New York State Secretary of State for each incorporated individual PEO.
Attach a blank copy of the contract used with clients.
Attach a list of all New York clients including the name, address, FEIN, type of business, name of the New
York State Workers’ Compensation and Disability Insurance policyholders, and number of employees for
each client. This list will be kept confidential.
Attach Form CE 200. Information and a copy of this form are available from any District Office of the New
York State Workers’ Compensation Board or from their website at www.wcb.ny.gov; click on “WC/DB
Exemptions,” then click on “Request for WC/DB Exemption.”
The law does not permit Group exemption. Each PEO must apply individually.
Attach a copy of your PEO Registration from another state that has the same, or greater, requirements as NYS.
If a corporation, the application must be signed by the chief executive officer of the corporation.
If a partnership, proprietorship or LLC the application must be signed by a partner, owner or member
authorized to bind the entity.
Mail the completed request with all attachments to:
New York State Department of Labor
Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, NY 12240
E. Declaration
By filing this request, the applicant authorizes the Unemployment Insurance Division to release its Unemployment
Insurance records to the Division of Labor Standards.
I, the undersigned, affirm that I am an officer, partner, proprietor or member of the above Applicant PEO and am
authorized to file this request for exemption. I affirm that the Applicant PEO meets all the requirements for exemption
listed in Section A. Qualifications for Exemption of this form. I affirm that the information in this request and all
attachments is complete and accurate to the best of my knowledge.
Date
Signature of Chief Executive Officer, Partner,
Sole Proprietor or Member
Print name of above Signatory
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