Form UI-1 Status Registration - Mississippi

Form UI-1 or the "Status Registration" is a form issued by the Mississippi Department of Employment Security.

The form was last revised in December 1, 2006 and is available for digital filing. Download an up-to-date Form UI-1 in PDF-format down below or look it up on the Mississippi Department of Employment Security Forms website.

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Mississippi Department of Employment Security
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UI-1
STATUS REGISTRATION
Please type or print. Always complete entire form.
MDES OFFICIAL INFORMATION
Found Date
(MM/DD/CCYY):
DO NOT WRITE ABOVE THIS LINE.
EMPLOYER ENTITY INFORMATION
-
1. Federal Employer ID Number (FEIN):
2. Organization Type:
Corporation
Partnership
Individual
Non-Profit Corp.
Corporate LLC
Partnership LLC
Individual LLC
Other (enter type):
3. IF A CORPORATION: a. State of Incorporation:
b. Date of Incorporation
c. State of Legal Domicile:
(MM/DD/CCYY):
4. IF INDIVIDUAL OWNER:
Do you employ any individual(s) not including yourself, your spouse or your children under 21 years of age? YES
NO
5. Legal Entity Name:
6. Business Name (D/B/A):
7. a. If Yes, provide the date
you first
(MM/DD/CCYY)
7. Have you paid employees for work performed in Mississippi?
YES
NO
employed someone in Mississippi:
8. Does this business consist solely of agricultural work?
YES
NO
9. Does this business employ domestic help?
YES
NO
(This includes housekeepers, sitters, or other domestic employment)
10. Are you applying for reimbursable status under the Indian Tribal Law?
YES
NO
11. Is this organization a State College, State University or State Hospital?
YES
NO
12. Is this business FUTA (Federal Unemployment Tax) liable in another state?
YES
NO
13. Are you a Professional Baseball Concessionaire?
YES
NO
14. Do you have a Third Party that handles your payoll and/or tax matters?
YES
NO
a. If Yes, Third Party authorized to handle matters for Unemployment Tax:
b. Agent/Officer Phone:
Name:
-
(
)
ext.
Title:
15. Do you have business location(s) in Mississippi?
YES
NO
a. If Yes, list below your places of business in Mississippi and give a description of your operations at each place of business.
City
County
Number of Employees
Principal Business Activity
16. Are you exempt as an IRS 501 (C) (3) Non-Profit Organization?
YES
NO
a. If Yes, attach a copy of your 501(C) (3) exemption.
EMPLOYER CONTACT DETAILS
1. Physical Address
Address:
City:
State:
Country:
ZIP Code:
-
Phone:
(
)
2. Unemployment Tax Mailing Address
Same as previous
Attention:
Address:
City:
State:
Country:
ZIP Code:
-
Phone: (
)
-
Contact Name (First, MI, Last):
Phone: (
)
ext.
3. Unemployment Claims Mailing Address Same as previous
Address:
City:
State:
Country:
ZIP Code:
Phone: (
)
-
FAX: (
)
-
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address: www.mdes.ms.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Page 1 of 3
Mississippi Department of Employment Security
|
M
|
D
|
E
|
S
|
|
M
|
D
|
E
|
S
|
UI-1
STATUS REGISTRATION
Please type or print. Always complete entire form.
MDES OFFICIAL INFORMATION
Found Date
(MM/DD/CCYY):
DO NOT WRITE ABOVE THIS LINE.
EMPLOYER ENTITY INFORMATION
-
1. Federal Employer ID Number (FEIN):
2. Organization Type:
Corporation
Partnership
Individual
Non-Profit Corp.
Corporate LLC
Partnership LLC
Individual LLC
Other (enter type):
3. IF A CORPORATION: a. State of Incorporation:
b. Date of Incorporation
c. State of Legal Domicile:
(MM/DD/CCYY):
4. IF INDIVIDUAL OWNER:
Do you employ any individual(s) not including yourself, your spouse or your children under 21 years of age? YES
NO
5. Legal Entity Name:
6. Business Name (D/B/A):
7. a. If Yes, provide the date
you first
(MM/DD/CCYY)
7. Have you paid employees for work performed in Mississippi?
YES
NO
employed someone in Mississippi:
8. Does this business consist solely of agricultural work?
YES
NO
9. Does this business employ domestic help?
YES
NO
(This includes housekeepers, sitters, or other domestic employment)
10. Are you applying for reimbursable status under the Indian Tribal Law?
YES
NO
11. Is this organization a State College, State University or State Hospital?
YES
NO
12. Is this business FUTA (Federal Unemployment Tax) liable in another state?
YES
NO
13. Are you a Professional Baseball Concessionaire?
YES
NO
14. Do you have a Third Party that handles your payoll and/or tax matters?
YES
NO
a. If Yes, Third Party authorized to handle matters for Unemployment Tax:
b. Agent/Officer Phone:
Name:
-
(
)
ext.
Title:
15. Do you have business location(s) in Mississippi?
YES
NO
a. If Yes, list below your places of business in Mississippi and give a description of your operations at each place of business.
City
County
Number of Employees
Principal Business Activity
16. Are you exempt as an IRS 501 (C) (3) Non-Profit Organization?
YES
NO
a. If Yes, attach a copy of your 501(C) (3) exemption.
EMPLOYER CONTACT DETAILS
1. Physical Address
Address:
City:
State:
Country:
ZIP Code:
-
Phone:
(
)
2. Unemployment Tax Mailing Address
Same as previous
Attention:
Address:
City:
State:
Country:
ZIP Code:
-
Phone: (
)
-
Contact Name (First, MI, Last):
Phone: (
)
ext.
3. Unemployment Claims Mailing Address Same as previous
Address:
City:
State:
Country:
ZIP Code:
Phone: (
)
-
FAX: (
)
-
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address: www.mdes.ms.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Page 1 of 3
UI-1
STATUS REGISTRATION
2
4. Payroll Mailing Address
Same as previous
Address:
City:
State:
Country:
ZIP Code:
-
-
Phone: (
)
FAX: (
)
5. Officer or Resident Agent authorized to furnish payroll information:
Name:
Title:
6. Preferred Mode of Correspondence:
USPS
E-Mail
Telephone
FAX
Other (enter type):
7. Employer E-Mail Address:
BUSINESS OWNERSHIP
1. List the Name, Title, Social Security Number and Address of the Proprietor, Partners or Corporate Officers.
NAME (First, MI, Last)
TITLE
SSN
ADDRESS
-
-
-
-
-
-
2. Beginning Date of Employment in Mississippi
:
3. Date Acquired
:
(MM/DD/CCYY)
(MM/DD/CCYY)
4. Did you acquire (purchase, inherit, etc) this business?
Yes
No
If yes, provide details about the previous owner below.
a. Name this business was operating under (Doing Business As):
b. Federal Employer Identification Number (FEIN)
-
d. MDES Employer Account Number (EAN):
c. Previous Owner’s Current Address:
-
-
-
-
e. Phone:
(
)
ext.
f. Does this business continue to operate?
Yes
No
5. Have you ever been registered with the Mississippi Department of Employment Security?
Yes
No
-
-
-
a. If Yes, provide previous MDES Employer Account Number (EAN):
-
b. If Yes, provide previous Federal Employer Identification Number (FEIN):
LAST CALENDAR YEAR 20____
Indicate in each space the TOTAL WAGES you paid during each calendar quarter in the Last Calendar Year.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Each box represents a Calendar Week. Indicate by Calendar Week the number of people working for you during each week of the Last Calendar Year.
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
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28th
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33rd
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40th
41st
42nd
43rd
44th
45th
46th
47th
48th
49th
50th
51st
52nd
53rd
xx
xx
xx
CURRENT CALENDAR YEAR 20____
Indicate in each space the TOTAL WAGES you paid during each calendar quarter in the Current Calendar Year.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Each box represents a Calendar Week. Indicate by Calendar Week the number of people working for you during each week of the Current Calendar
Year.
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address: www.mdes.ms.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Page 2 of 3
UI-1
STATUS REGISTRATION
3
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I hereby certify that all the information contained above is true and correct to the best of my knowledge.
Date
:
Firm Name:
(MM/ DD /CCYY)
Signature:
Title:
Mississippi Department of Employment Security is an equal opportunity employer.
UI-1 R-12/2006
Web Address: www.mdes.ms.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Page 3 of 3

Download Form UI-1 Status Registration - Mississippi

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