Form Me. FX-1L "Employer's Status Report (For Subject Employee Leasing Clients)" - Maine

What Is Form Me. FX-1L?

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

Form Details:

  • Released on June 1, 2011;
  • The latest edition provided by the Maine 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 Me. FX-1L by clicking the link below or browse more documents and templates provided by the Maine Department of Labor.

ADVERTISEMENT
ADVERTISEMENT

Download Form Me. FX-1L "Employer's Status Report (For Subject Employee Leasing Clients)" - Maine

Download PDF

Fill PDF online

Rate (4.3 / 5) 25 votes
MAINE DEPARTMENT OF LABOR
OFFICE USE ONLY
Bureau of Unemployment Compensation – Tax Division
Employer No.
45 Commerce Drive, 47S State House Station
Area Code
Augusta, ME 04333-0047
Industry Code
Liability Established
EMPLOYER’S STATUS REPORT (For Subject Employee Leasing Clients)
Chargeable
As a Client of an Employee Leasing Company, you are required to complete this form. If you have any questions regarding
this form, please contact this Department using one of the choices in the “Questions” box on the reverse side.
1. Leasing Company Name
1a. Leasing Company Mailing Address and Zip Code
1b. Leasing Company Federal ID No.
1c. Leasing Company State ID No.
2. Client Company Name
2a. Client Company Federal ID No.
3. Client Company Address
4. Name of Person in Charge of Payroll Records at Client Co.
Phone:
Fax:
5.
Type of Organization: A.
Individual Ownership; B.
Partnership C.
Corporation; D.
Association
E.
“S” Corporation (attach Federal Form 2553); F.
LLC; G.
Other (Explain):
6.
State of Incorporation
7. Date of Incorporation
8.
Date Employees First Employed in Maine:
8a. Date You Began Leasing Employees from Above Leasing Company in Maine:
8b. Do You Lease All of Your Workers?.....................................................................................................
YES
NO
9. Name of Client Owner(s), Partner(s), Officers
Residence
Name
Social Security No.
Title
(Street-City-State-Zip Code)
10. If you acquired the business or assets of another employing unit, give name, address, and account number of previous owner.
Name
Address
UC Account No.
Date Acquired
Sales Tax Registration No.
Did you acquire all the business in Maine? ...........................................................................................
YES
NO
Did the previous owner do business in Maine?.....................................................................................
YES
NO
Did the previous owner have employment in Maine? ...........................................................................
YES
NO
11. What part of the previous owner’s business did you not acquire?
12. Is your organization subject to the Federal Unemployment Tax? (If unknown, leave blank................
YES
NO
13. Do you hold an exemption from federal income taxes as a nonprofit organization described
under Section 501(c)(3) of the internal revenue code?..................................................................... *
YES
NO
* If “YES,” you must attach a copy of your IRS exemption letter
14. Have you engaged any contractors or subcontractors to perform any service for you which
was part of your usual course of business, in the current or preceding year?................................ **
YES
NO
** If “YES,” give name and address on separate sheet and attach to this report.
15. Do any of your workers provide domestic service for you?..................................................................
YES
NO
16. Do any of your workers provide agricultural service for you? ..............................................................
YES
NO
NOTE: If the answer is “YES,” to either question 15 or 16, please indicate in items 17 and 18 of this report which wages
and employees relate to each category. Attach a separate sheet if necessary.
Me. FX-1L (rev. 06/2011)
> > Please Complete Reverse Side < <
MAINE DEPARTMENT OF LABOR
OFFICE USE ONLY
Bureau of Unemployment Compensation – Tax Division
Employer No.
45 Commerce Drive, 47S State House Station
Area Code
Augusta, ME 04333-0047
Industry Code
Liability Established
EMPLOYER’S STATUS REPORT (For Subject Employee Leasing Clients)
Chargeable
As a Client of an Employee Leasing Company, you are required to complete this form. If you have any questions regarding
this form, please contact this Department using one of the choices in the “Questions” box on the reverse side.
1. Leasing Company Name
1a. Leasing Company Mailing Address and Zip Code
1b. Leasing Company Federal ID No.
1c. Leasing Company State ID No.
2. Client Company Name
2a. Client Company Federal ID No.
3. Client Company Address
4. Name of Person in Charge of Payroll Records at Client Co.
Phone:
Fax:
5.
Type of Organization: A.
Individual Ownership; B.
Partnership C.
Corporation; D.
Association
E.
“S” Corporation (attach Federal Form 2553); F.
LLC; G.
Other (Explain):
6.
State of Incorporation
7. Date of Incorporation
8.
Date Employees First Employed in Maine:
8a. Date You Began Leasing Employees from Above Leasing Company in Maine:
8b. Do You Lease All of Your Workers?.....................................................................................................
YES
NO
9. Name of Client Owner(s), Partner(s), Officers
Residence
Name
Social Security No.
Title
(Street-City-State-Zip Code)
10. If you acquired the business or assets of another employing unit, give name, address, and account number of previous owner.
Name
Address
UC Account No.
Date Acquired
Sales Tax Registration No.
Did you acquire all the business in Maine? ...........................................................................................
YES
NO
Did the previous owner do business in Maine?.....................................................................................
YES
NO
Did the previous owner have employment in Maine? ...........................................................................
YES
NO
11. What part of the previous owner’s business did you not acquire?
12. Is your organization subject to the Federal Unemployment Tax? (If unknown, leave blank................
YES
NO
13. Do you hold an exemption from federal income taxes as a nonprofit organization described
under Section 501(c)(3) of the internal revenue code?..................................................................... *
YES
NO
* If “YES,” you must attach a copy of your IRS exemption letter
14. Have you engaged any contractors or subcontractors to perform any service for you which
was part of your usual course of business, in the current or preceding year?................................ **
YES
NO
** If “YES,” give name and address on separate sheet and attach to this report.
15. Do any of your workers provide domestic service for you?..................................................................
YES
NO
16. Do any of your workers provide agricultural service for you? ..............................................................
YES
NO
NOTE: If the answer is “YES,” to either question 15 or 16, please indicate in items 17 and 18 of this report which wages
and employees relate to each category. Attach a separate sheet if necessary.
Me. FX-1L (rev. 06/2011)
> > Please Complete Reverse Side < <
Items 17 and 18
All Corporations: Include all officers and family members who are performing services.
All Employers: Do not include service performed by a student participating in a cooperative program of education and
occupational training.
Proprietorship: Do not include the service performed by an individual in the employ of his son, daughter or spouse, or
the service performed by a child under 18 for his farther or mother.
Partnership: Do not include partners.
* TO INSURE PROMPT PROCESSING, PLEASE COMBINE DATA FOR NON-LEASED AND LEASED WORKERS
*17.
In the spaces below, enter the total amount of reportable wages paid each quarter of the current and preceding
calendar years (include wages paid to date).
Quarter Ending
Quarter Ending
Quarter Ending
Quarter Ending
Maine Payrolls
March 31
June 30
September 30
December 31
Preceding Year 20__
Current Year 20__
*18.
If you are either a 501(c)(3) or an agricultural employer, enter in each block the largest number of individuals, both full
and part-time workers, who were employed by you in Maine in your peak day of employment in each week. All other
employers, please use check marks indicating weeks with workers.
Preceding
Week #
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Year
20______
Week #
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Current
Week #
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Year
20_____
Week #
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
19.
List all Maine work locations:
Nature of Business
City and/or Town
No. of Employees
Principal Activity
Type of Goods or Services
20.
FOR MULTIPLE LOCATIONS AND/OR ACTIVITIES: If one of the above locations is an auxiliary unit for the primary
establishment, please indicate by putting the appropriate letter next to the activity:
(A) = Administrative Office;
(B) = Research, Development and Testing; (C) = Warehouse and Storage Area; (D) = Auxiliaries, Not Classified
(Repair Shops, Computer Maintenance, Garages, etc.).
21.
I CERTIFY THE INFORMATION GIVEN ABOVE IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
AND BELIEF. THIS REPORT MUST BE SIGNED BY AN OWNER, PARTNER, OR OFFICER.
Signature: Client Company Owner/Corporate Officer/Partner
Title
Signature of Partner
Date
22.
Liability Established under Section 1043,9
as of
. Contributions due from
.
Field Advisor and Examiner
Code
Date
QUESTIONS?
Contact a Representative at (207) 621-5120; TTY (Deaf / Hard of Hearing): 1-800-794-1110,
Fax at (207) 287-3733, e-mail at division.uctax@Maine.gov, or contact a Field Advisor and Examiner at one of the
numbers below:
Augusta............ (207) 621-5120
Lewiston ............(207) 753-9088
Saco.................. (207) 286-2677
Bangor ............. (207) 561-4094
Portland.............(207) 822-0212
Wilton................ (207) 645-5825
Brunswick......... (207) 373-4009
Presque Isle ......(207) 768-6813
Page of 2