STATE OF ALABAMA
DEPARTMENT OF LABOR
UNEMPLOYMENT COMPENSATION DIVISION
649 MONROE STREET
MONTGOMERY, ALABAMA 36131
STATUS UNIT: (334) 954-4730 FAX: (334) 954-4731
EMAIL: [email protected]
www.labor.alabama.gov
APPLICATION TO DETERMINE LIABILITY
IMPORTANT NOTICE
Under Alabama law you are required to furnish the information requested on this application. Each false statement or refusal to furnish information on this report, or willful refusal to make contributions or other payments is punishable by fine or imprisonment, or both, and each day of such refusal shall constitute a separate offense.
EMPLOYER NAME AND MAILING ADDRESS
FEDERAL EMPLOYER I.D. NUMBER (FEIN)
This number is assigned by the Internal Revenue Service
1.Mark (x) one type of employment. A separate form must be filed for each type of employment.
NON-FARM |
AGRICULTURE |
DOMESTIC |
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GOVERNMENT: STATE |
LOCAL |
2. Do you have a previous Alabama Unemployment Compensation Account? YES |
NO |
2a. If yes, account number: |
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3. Do you have employees located in another state? YES |
NO |
4.Is your firm subject to the Federal Unemployment Tax Act (FUTA)?
3a. If yes, in what state(s)?
YES |
NO |
4a. If yes, year liability first incurred: |
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4b. |
Have you remained liable since that date? |
YES |
NO |
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5. |
Did you start a new business? YES |
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NO |
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5a. |
If no, did you acquire an ongoing business? YES |
NO |
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5b. |
Date Alabama employment began: |
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5c. Date payroll began: |
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6. |
If you acquired ALL |
or PART |
of an ongoing business, enter the NAME,TRADE TITLE and ADDRESS of your predecessor employer: |
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6a. |
Predecessor's telephone number (if known): |
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6b. Predecessor FEIN (if known): |
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6c. If your predecessor was liable in Alabama, enter their Alabama Unemployment Account Number (if known):
6d. Date acquired from predecessor:
6f. If yes, date discontinued:
6e. Did your predecessor discontinue business? YES |
NO |
7.List below TOTAL ALABAMA WAGES paid to all employees during each calendar quarter of each year from the date in Item 5b. Include remuneration paid to officers of corporations and wages of part-time employees for current year and previous year, if applicable.
8.List below, by type of employment, the number of individuals in your employ within each week. A month with five Saturdays is considered to have five weeks of employment. Include all part-time employees and officers remunerated by corporations.
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WEEK |
JAN |
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MAR |
APR |
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JUN |
JUL |
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SEP |
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OCT |
NOV |
DEC |
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FEB |
MAY |
AUG |
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Current |
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1st |
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Year |
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2nd |
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3rd |
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4th |
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5th |
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Previous |
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1st |
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2nd |
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Year |
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3rd |
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4th |
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5th |
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FORM SR2 |
(Rev. 6-2012), CAT NO 53270 IMPORTANT: Please complete this application, Questions 1-14. |
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PAGE 1 OF 2 |
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9.ITEM 9 MUST BE COMPLETED IN ITS ENTIRETY. Use the enclosed instruction sheet for Item 9 to complete Columns 1-5; refer questions to LMI at 334-954-7447. Please Be Specific. List each location and type of operation or activity separately. (Attach additional sheets if necessary.)
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Column |
Column |
Column |
Column |
Column |
Name |
1 |
2 |
3 |
4 |
5 |
Location |
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Name and location -- Each unit in Alabama |
Alabama |
Employee |
Indicate specific type of activity in detail |
Enter |
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Enter "Statewide" if no permanent location |
County |
count per |
See Instructions Sheet for Assistance |
Percent |
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unit |
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% |
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% |
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% |
%
9a. |
Is the above work site primarily engaged in performing support or services for other work sites of the company? YES |
NO |
9b. |
To whom are most of your products sold? GENERAL PUBLIC |
CONSTRUCTION CONTRACTORS |
RETAILERS |
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WHOLESALERS |
OTHERS |
(Specify) |
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10. Form of organization: INDIVIDUAL |
PARTNERSHIP |
CORPORATION |
ASSOCIATION |
ESTATE OR TRUST |
LLC (see 10a.) |
NON-PROFIT ORGANIZATION (see 10b.) |
OTHER |
(Specify) |
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10a. Indicate tax filing status with IRS (include all members and their social security numbers or Federal Identification numbers in Item 11)
CORPORATION |
PARTNERSHIP |
SOLE PROPRIETOR |
DISREGARDED ENTITY |
10b. Is the organization exempt under 501(c)(3) of the IRS Code? YES |
NO |
(If yes, submit a copy of the 501(c)(3) letter of exemption.) |
11. For positive identification, list below the full name(s), social security number(s) and title(s) of individual owner, partners or officers.
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12. |
If not otherwise subject, do you wish to voluntarily elect coverage under the Alabama Law? YES |
NO |
13. |
Name and business location/physical address: |
13a. Tax Preparer/CPA/Accountant: |
Name of Applicant, Employer, Corporation, Partnership, Trust, etc.
Trade Name or Division (if different from above)
Physical Address
City |
County |
State |
Zip |
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Area Code – Telephone |
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Area Code – Facsimile |
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Contact Person |
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Email Address |
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Name of Tax Preparer/CPA/Accountant
Trade Name or Division (if different from above)
Address
City |
County |
State |
Zip |
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Area Code – Telephone |
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Area Code – Facsimile |
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Contact Person |
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Email Address |
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I certify the information provided on this application is true and correct to the best of my knowledge.
14. Business Name:Signature:Date:
NOTE: IF CPA, TAX PREPARER, ETC., IS ONLY SIGNATURE, PLEASE ENCLOSE POWER OF ATTORNEY.
FORM SR2 (Rev. 6-2012), CAT NO 53270 IMPORTANT: Please complete this application, Questions 1-14. |
PAGE 2 OF 2 |