State Form 55109 "Unemployment Insurance Tax Protest" - Indiana

This version of the form is not currently in use and is provided for reference only.
Download this version of State Form 55109 for the current year.

What Is State Form 55109?

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

Form Details:

  • Released on September 1, 2012;
  • The latest edition provided by the Indiana Department of Workforce Development;
  • 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 fillable version of State Form 55109 by clicking the link below or browse more documents and templates provided by the Indiana Department of Workforce Development.

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Download State Form 55109 "Unemployment Insurance Tax Protest" - Indiana

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INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
UNEMPLOYMENT INSURANCE TAX PROTEST
Attention: Director, UI Tax Administration
State Form 55109 (9-12)
10 North Senate Avenue, SE 202
Indianapolis, Indiana 46204
Telephone: (317) 232-7698
Fax: (317) 233-9226
Website: www.in.gov/dwd/
CONFIDENTIAL RECORD PURSUANT TO IC 22-4-19-6, IC 4-1-6
PROTESTING PARTY INFORMATION
Name of protesting party
Date of protest (month, day, year)
Employer Identification Number / Taxpayer Identification Number
SUTA account number
FOR INTERNAL EMPLOYER REPRESENTATIVE ONLY
Name of contact
Job title / relationship to business
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
FOR EXTERNAL EMPLOYER REPRESENTATIVE ONLY
Name of contact
Job title / relationship to business
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
REASON FOR PROTEST (Check all that apply.)
Merit Rate Calculation
Rate Assurance
Acquisition / Disposition
Estimations
Blocked Wage Claim
Other Liabilities
Compliance Audit
Are you represented by counsel?
Yes
No
If “Yes”, please provide contact information.
Name of attorney
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
Reset Form
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
UNEMPLOYMENT INSURANCE TAX PROTEST
Attention: Director, UI Tax Administration
State Form 55109 (9-12)
10 North Senate Avenue, SE 202
Indianapolis, Indiana 46204
Telephone: (317) 232-7698
Fax: (317) 233-9226
Website: www.in.gov/dwd/
CONFIDENTIAL RECORD PURSUANT TO IC 22-4-19-6, IC 4-1-6
PROTESTING PARTY INFORMATION
Name of protesting party
Date of protest (month, day, year)
Employer Identification Number / Taxpayer Identification Number
SUTA account number
FOR INTERNAL EMPLOYER REPRESENTATIVE ONLY
Name of contact
Job title / relationship to business
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
FOR EXTERNAL EMPLOYER REPRESENTATIVE ONLY
Name of contact
Job title / relationship to business
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
REASON FOR PROTEST (Check all that apply.)
Merit Rate Calculation
Rate Assurance
Acquisition / Disposition
Estimations
Blocked Wage Claim
Other Liabilities
Compliance Audit
Are you represented by counsel?
Yes
No
If “Yes”, please provide contact information.
Name of attorney
Mailing address (number and street, city, state, and ZIP code)
E-mail address
Telephone number (including extension)
Fax number
(
)
(
)
Please provide additional information regarding the basis for your protest. The notice of determination or liability being protested
must be attached. Any additional documentation supporting your protest should also be attached to this form.
EMPLOYEE / EMPLOYER REPRESENTATIVE SIGNATURE
Signature
Printed name
YOUR PROTEST RIGHTS AND RESPONSIBILITIES AS AN EMPLOYER
646 IAC 5-10-25 Proceedings before the liability administrative law judge
Authority: IC 22-4-18-1; IC 22-4.1-3-3
Affected: IC 22-4-32-4; IC 22-4.1
Sec. 25. (a) Any protest filed by an employer under IC 22-4-32-4 must contain the cause or grounds for the protest, and the particular fact or facts
relied upon to support the protest. The protesting employer may file either on the form provided by the department for that purpose or on any
other document that shows an intent to protest the department's determination. The employer:
(1) must sign the protest; and
(2) shall file the protest with the commissioner.
(b) After the protest is received by the commissioner, the commissioner, or the commissioner's designee, shall refer the protest to the liability
administrative law judge, who will set the date, time, and place for the hearing. The hearing will be scheduled to be held no fewer than ten (10)
days following the mailing date of the notice of hearing.
(c) By permission of the liability administrative law judge, the employer may amend its protest at any time prior to the beginning of the hearing.
The hearing will be confined to the issues raised by the employer's protest.
(d) Unless the employer's protest is filed within the statutory time period, the department's liability determination shall be considered to be
correct and final.
(e) The liability administrative law judge shall have no jurisdiction to determine the benefit rights of any individual to whom benefits have been
paid as the result of a final determination. (Department of Workforce Development; 646 IAC 5-10-25; filed Apr 26, 2011, 11:23 a.m.: 20110525-
IR-646100464FRA)
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