Form UC-1A "Employer Status Report for Unemployment Compensation" - Connecticut

What Is Form UC-1A?

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

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Connecticut 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 fillable version of Form UC-1A by clicking the link below or browse more documents and templates provided by the Connecticut Department of Labor.

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Download Form UC-1A "Employer Status Report for Unemployment Compensation" - Connecticut

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ABC
Over 6
Lag Date
UC-1A (Rev 1/14)
Registration
EMPLOYER STATUS REPORT
IC
Under 6
___________
Number: ______________________
For UNEMPLOYMENT
666
148
COMPENSATION
________________________For Office Use Only
151
713
Status ___________________________________
Other ______________________
Rate(s)___________________________________
Quarter(s)_________________________________
Predecessor Reg. No.:
Date Rec’d
___________________________
RETURN COMPLETED FORM TO:
FORM IS TO BE TYPED OR PRINTED IN INK
EMPLOYER STATUS UNIT
PLEASE COMPLETE AND RETURN THIS FORM EVEN THOUGH YOU MAY NOT BE SUBJECT TO THE
200 FOLLY BROOK BLVD.
CONNECTICUT UNEMPLOYMENT COMPENSATION LAW. *501(C)(3) NON-PROFIT ORGANIZATIONS SHOULD
WETHERSFIELD, CT 06109-1114
REQUEST FORM UC-1NP. THE STATE OF CONNECTICUT OR ITS MUNICIPALITIES SHOULD REQUEST FORM
TEL. NO. (860) 263-6550
FAX (860) 263-6567
UC-1MUN.
. (
)
_____________
1. Federal Identification Number _______________ Tel. No
______________ Email Address _________________________
2. Business or Trade Name_____________________________________________________________________________________________________
3. Name of Owner, Partners, or
Corporate name, if other than above_____________________________________________________________________________________________
4. Mailing
address___________________________________________________________________________________________________________________
Street or P.O. Box
City
Number
State
Zip Code
5. List all Connecticut business locations, if different from above. If mailing address is P.O. Box, please give the physical location of business. Attach a
separate sheet if necessary. If only a salesman in Connecticut, please indicate salesman’s home address.
___________________________________________________________________________________________________________
6a. Describe the exact nature of the business. If construction, state the type. If manufacturing, list the principal products sold and their percent of the
total. If trade, state whether retail or wholesaler and list the type of products sold. If employer of HOUSEHOLD help, so indicate.
_________________________________________________________________________________________________________
6b. State function of the Connecticut facility (i.e., headquarters, research facilities, etc.)___________________________________________________
7a. Under what type of business organization do you operate? (Check one of the following)
Individual / Sole Proprietorship
Partnership
Corporation
Other__________________________________________________
:
LLC – Sole Proprietor
LLC - Partnership
LLC – Corporation
LIMITED LIABILITY COMPANIES
7b. Corporations or LLC's complete this item:
State in which Incorporated/Organized: __________________________ Date of Incorporation/Organization: ________________________________
MM / DD / YY
8.
List proprietor, partners, corporation officers, or members of a L.L.C. (Attach a separate sheet if necessary):
Name
SS #
Title
Home Address – including Zip Code (Not a P.O. Box)
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
9. When did you first engage employees working in Connecticut under your present type of organization? _____________________________________
MM / DD / YY
Note: Officers of a corporation are considered employees for unemployment purposes.
10. Did you acquire ALL or PART of the employees, or assets, or organization, or trade and business in Connecticut of some other employer?
.
Note: Acquisition can be facilitated by a third party such as a bank or court
Yes
No
If Yes, All
Part
If only part, describe what part was acquired:__________________________________________ Date Acquired _________________________
What part was not acquired?_______________________________________________________
MM / DD / YY
Is your business owned by the same interests as the predecessor?
Yes
No
11. If the answer to Item 10 is “Yes”, complete the following:
1. Previous Employer’s Trade Name ________________________________________________________________________________________
2. Name and address of previous proprietor, partner,
or corporation officer___________________________________________________________________________________________________
3. Was the previous employer subject to Connecticut Unemployment Compensation Law?
Yes
No
Previous registration number_____________________________________________
Yes
4. Will the previous employer remain in business in Connecticut?
No
12. Were you previously or are you now registered as an employer with the Connecticut Labor Department?
Yes
No If “Yes”, indicate registration number__________________________________________________________________________
ABC
Over 6
Lag Date
UC-1A (Rev 1/14)
Registration
EMPLOYER STATUS REPORT
IC
Under 6
___________
Number: ______________________
For UNEMPLOYMENT
666
148
COMPENSATION
________________________For Office Use Only
151
713
Status ___________________________________
Other ______________________
Rate(s)___________________________________
Quarter(s)_________________________________
Predecessor Reg. No.:
Date Rec’d
___________________________
RETURN COMPLETED FORM TO:
FORM IS TO BE TYPED OR PRINTED IN INK
EMPLOYER STATUS UNIT
PLEASE COMPLETE AND RETURN THIS FORM EVEN THOUGH YOU MAY NOT BE SUBJECT TO THE
200 FOLLY BROOK BLVD.
CONNECTICUT UNEMPLOYMENT COMPENSATION LAW. *501(C)(3) NON-PROFIT ORGANIZATIONS SHOULD
WETHERSFIELD, CT 06109-1114
REQUEST FORM UC-1NP. THE STATE OF CONNECTICUT OR ITS MUNICIPALITIES SHOULD REQUEST FORM
TEL. NO. (860) 263-6550
FAX (860) 263-6567
UC-1MUN.
. (
)
_____________
1. Federal Identification Number _______________ Tel. No
______________ Email Address _________________________
2. Business or Trade Name_____________________________________________________________________________________________________
3. Name of Owner, Partners, or
Corporate name, if other than above_____________________________________________________________________________________________
4. Mailing
address___________________________________________________________________________________________________________________
Street or P.O. Box
City
Number
State
Zip Code
5. List all Connecticut business locations, if different from above. If mailing address is P.O. Box, please give the physical location of business. Attach a
separate sheet if necessary. If only a salesman in Connecticut, please indicate salesman’s home address.
___________________________________________________________________________________________________________
6a. Describe the exact nature of the business. If construction, state the type. If manufacturing, list the principal products sold and their percent of the
total. If trade, state whether retail or wholesaler and list the type of products sold. If employer of HOUSEHOLD help, so indicate.
_________________________________________________________________________________________________________
6b. State function of the Connecticut facility (i.e., headquarters, research facilities, etc.)___________________________________________________
7a. Under what type of business organization do you operate? (Check one of the following)
Individual / Sole Proprietorship
Partnership
Corporation
Other__________________________________________________
:
LLC – Sole Proprietor
LLC - Partnership
LLC – Corporation
LIMITED LIABILITY COMPANIES
7b. Corporations or LLC's complete this item:
State in which Incorporated/Organized: __________________________ Date of Incorporation/Organization: ________________________________
MM / DD / YY
8.
List proprietor, partners, corporation officers, or members of a L.L.C. (Attach a separate sheet if necessary):
Name
SS #
Title
Home Address – including Zip Code (Not a P.O. Box)
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
_________________________ _______________ _________________ _____________________________________________
9. When did you first engage employees working in Connecticut under your present type of organization? _____________________________________
MM / DD / YY
Note: Officers of a corporation are considered employees for unemployment purposes.
10. Did you acquire ALL or PART of the employees, or assets, or organization, or trade and business in Connecticut of some other employer?
.
Note: Acquisition can be facilitated by a third party such as a bank or court
Yes
No
If Yes, All
Part
If only part, describe what part was acquired:__________________________________________ Date Acquired _________________________
What part was not acquired?_______________________________________________________
MM / DD / YY
Is your business owned by the same interests as the predecessor?
Yes
No
11. If the answer to Item 10 is “Yes”, complete the following:
1. Previous Employer’s Trade Name ________________________________________________________________________________________
2. Name and address of previous proprietor, partner,
or corporation officer___________________________________________________________________________________________________
3. Was the previous employer subject to Connecticut Unemployment Compensation Law?
Yes
No
Previous registration number_____________________________________________
Yes
4. Will the previous employer remain in business in Connecticut?
No
12. Were you previously or are you now registered as an employer with the Connecticut Labor Department?
Yes
No If “Yes”, indicate registration number__________________________________________________________________________
You are liable for the CT and Federal Unemployment Tax if (a) during any calendar quarter of the current or preceding year you paid
wages totaling $1,500 or more, or (b) you had, during the current or preceding calendar year, one or more employees at any time in
each of 20 calendar weeks.
13.
Were you required to file the EMPLOYER’S FEDERAL UNEMPLOYMENT TAX RETURN Treasury Form 940 for any part of the
preceding three completed calendar years? YES
NO
If “yes”, indicate the years: ________ _______ ________
14.
As of the date of this application, have you met the liability requirements for this current calendar year? YES
NO
If NO, please complete 15 and 16:
15.
If you have engaged employees and anticipate meeting the liability requirements in this calendar year you will be
subject as of the first date you engaged employees. However, a Connecticut registration number can not be issued
until you actually meet the liability requirements, unless you voluntarily accept coverage. Do you wish to accept
coverage at this time? YES
NO
16.
If you have engaged employees and do NOT meet the liability requirements in this calendar year, but anticipate meeting
the liability requirements next year, you will be subject commencing January 1
.
However, a Connecticut registration
number can not be issued until you actually meet the liability requirements, unless you voluntarily accept coverage
commencing January 1. Do you wish to accept coverage? YES
NO
17.
List below the gross wages paid to individuals in your employ in Connecticut. Include FULL and PART-TIME employees and
OFFICERS, if a corporation. See UC-1A Instructions for the definition of gross wages.
st
nd
rd
th
1
Quarter
2
Quarter
3
Quarter
4
Quarter
(Jan. 1 – Mar 31)
(Apr. 1 – June 30)
(July 1 – Sept. 30)
(Oct. 1 – Dec. 31)
Current Year
____________
$______________
$______________
$______________
$_____________
Prior Year 1
____________
$______________
$______________
$______________
$_____________
Prior Year 2
____________
$______________
$______________
$______________
$_____________
Note: For Domestic (Household)
and Agricultural
please check box and list only cash wages above
18.
AGRICULTURAL EMPLOYERS – Did you employ 10 or more agricultural workers (excluding aliens admitted to the United
States pursuant to Sections 214 (c) and 101 (a)(15)(H) of the Immigration and Nationality Act) for some portion of a day during
any 20 calendar weeks, not necessarily consecutive, in either the preceding or current calendar year?
th
YES
NO
If “Yes”, list the week-ending date when the 20
week of employment was (or will be) met _______________
Did or will you pay cash wages of $20,000, or more in any calendar quarter of the preceding or current calendar year?
YES
NO
19.
DOMESTIC EMPLOYERS: Did or will you pay cash wages of $1,000, or more in any calendar quarter in either the preceding or
current year? YES
NO
20.
Do you have individuals performing services that you believe to be excluded from coverage or whom you believe to be
independent contractors?
YES
NO
If “Yes” explain below. (Attach separate sheet if necessary).
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
21.
Bank Name: ___________________________________________________________________________________________
Address and Account Number:_____________________________________________________________________________
22.
Name of accountant and/or payroll service, if any: _____________________________________________________________
Address and Telephone Number: __________________________________________________________________________
th
Please enter the total number of employees paid wages in Connecticut during the pay period which includes the 12
day of
23.
nd
rd
each month in the first quarter you reported employment? 1st Mo. _________ 2
Mo. __________ 3
Mo. ___________
THIS FORM MUST BE SIGNED BY THE OWNER, A PARTNER, CORPORATE OFFICER, OR AN AUTHORIZED EMPLOYEE.
ALL OTHERS MUST PROVIDE DOCUMENTATION OF AUTHORIZATION (I.E., POWER OF ATTORNEY).
I certify that the information in this report is true and correct.
Prepared By________________________________________
By_____________________________________________
(Signature)
(Signature)
Print Name _____________________________________
Print Name __________________________________________
Title ____________________________________________
Address ____________________________________________
Date ___________________________________________
Title ________________
Tel. Number __________________
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