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The New York LS 665 form serves as a crucial document for Professional Employer Organizations (PEOs) seeking registration in the state. This form is essential for both initial applications and renewals, ensuring that PEOs comply with state regulations. Applicants must provide detailed information about their business structure, including the name of the PEO or parent organization, type of business entity, and federal employer identification number. Additionally, the form requires applicants to disclose ownership details, listing individuals or entities with significant ownership stakes. Group applicants must also identify all member PEOs, including their addresses and FEINs. Submission instructions are clearly outlined, emphasizing the importance of timely application and the inclusion of necessary documentation, such as financial statements and proof of insurance. Furthermore, the LS 665 form mandates ongoing responsibilities, including quarterly reporting on tax compliance and client lists, reinforcing the accountability of PEOs operating within New York. By adhering to these requirements, PEOs can maintain their registration and operate legally in the state, thereby contributing to a structured and regulated labor environment.

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Division of Labor Standards

Permit and Certificate Unit

Harriman State Office Campus

Building 12, Room 185B

Albany, NY 12240

Professional Employer Organization

Request for Registration

A. Type of Request (check one)

Initial

Renewal for an individual Professional Employer Organization (PEO)

Initial

Renewal for a PEO Group (two or more PEOs that are majority owned by the same entity).

B. General Information (to be completed by individual and group applicants)

1a. Name of individual PEO or of parent organization (applicant) that has majority ownership of all members of the Group:

1b. Additional names, if any, under which the PEO currently conducts business:

2.Type of business organization (check one)

Corporation

Sole Proprietorship

Limited Liability Partnership

Partnership

Limited Liability Company

3.Federal Employer Identification Number (FEIN): __ __ - __ __ __ __ __ __ __

4a. Complete physical address of Principal Administrative Office:

4b. Mailing address, if different:

4c. Telephone, fax, and e-mail address of Principal Administrative Office: Telephone:

Fax: E-mail:

5a. List the current address of each additional office the individual PEO or parent organization maintains in New York. Use separate sheet of paper if necessary.

5b. Other than those in 5a., list the addresses of each office you maintained in New York during the past five years. Include any other names used and names of any predecessors and successors, if known. Use additional paper if necessary.

6. Fiscal year starts

and ends

LS 665 (06/20)

 

 

 

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C. Ownership Information (to be completed by individual and group applicants)

1a. If the applicant PEO is privately or closely held, list all persons or entities that own a five percent (5%) or greater interest in the individual PEO or the parent organization of the PEO group at the time of this application. Use additional paper if necessary.

Person or Entity

% Ownership

Address

1b. List all persons not listed above that have owned a five percent (5%) or greater interest in the individual PEO or the parent organization of the PEO group in the five years preceding the date of this application. Use additional paper if necessary.

Person or Entity

% Ownership

Address

2.If the applicant PEO or its parent company is a publicly traded company, list all persons or entities that own fifty percent (50%) or greater interest in the PEO or the parent company of the PEO.

Person or Entity

% Ownership

Address

D. Group Information (to be completed only by group applicants)

1a. List all the Professional Employer Organizations in the group. Include the FEIN and address for each PEO. Use additional paper if necessary.

PEO

FEIN

Address

1b. Additional names, if any, under which the PEOs conduct business.

2a. List the addresses of each additional office each member of the group maintains in New York. Use separate sheet of paper if necessary.

2b. Other than those in 2a., list the addresses of each office maintained by each member of the group in New York during the past five years. Include any other names used and names of predecessors and successors, if known. Use additional paper if necessary.

LS 665 (06/20)

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E. Submission Instructions (applicable to individual and group applicants)

•For any questions, email [email protected] or call (518) 457-1942.

•The initial PEO registration application must be submitted prior to operating in New York State. Renewal registration application(s) must be submitted no later than 180 days after the end of the PEO’s fiscal year.

•Make sure you have marked on the first page whether this is an initial or renewal request by an individual PEO or a PEO Group, and the Declaration and Group Guaranty, if applicable, on the next page are completed.

•With an initial request, submit a copy of the corporate filing receipt and/or authorization to do business in New York State from the New York State Secretary of State for each incorporated individual PEO, parent organization and PEO group member.

•Attach a blank client contract incorporating the requirements of Article 31 of the New York Labor Law and a sample written notice to worksite employees.

•Attach a list of all New York clients including the name, address, FEIN, type of business, name of the New York State Workers’ Compensation and Disability Insurance policyholders, and number of employees for each client. This list will be kept confidential. Attach a reviewed or audited financial statement of the PEO’s most recent fiscal year;

o The statement must have been prepared within 180 days prior to the submission by an independent certified public accountant (CPA) using generally accepted accounting principles (GAAP) and must show a minimum net worth of $75,000.

o The statement must be accompanied by a cover letter, signed by the independent CPA, certifying that (1) the statement fairly represents the financial position of the firm in accordance with GAAP and (2) there is reasonable assurance that the firm has timely paid all applicable federal and state payroll taxes on all New York employees (for example: office, worksite, etc.) for that fiscal year and explaining the basis for these certifications.

o A PEO Group may submit combined or consolidated audited or reviewed financial statements.

o Where the Group or the Group’s parent submit a combined or consolidated statement, supplemental consolidated or combined schedules covering each professional employer organization registered under the group must be included.

o If a bond or security is to be submitted in place of financial statements, email or call us for submission information.

•Attach proof of New York Workers’ Compensation and Disability Insurance:

oIf you have office and internal employees in New York, provide evidence of coverage for New York State Workers’ Compensation and

Disability Insurance by attaching copies of Form C-105.2 and DB-120.1 (Certificate of Insurance) that are available from your carrier(s).

oIf you have no office or internal employees in New York, attach Form CE-200. Information on and copies of this form are available from any District Office of the New York State Workers’ Compensation Board or from their website at www.wcb.ny.gov. Click on “WC/DB Exemptions”. Then click “Request for WC/DB Exemptions.”

•If a corporation, the request must be signed by an officer of the corporation authorized to bind the entity.

•If a partnership, proprietorship or LLC, the request must be signed by a partner, owner or member authorized to bind the entity.

•Mail the completed request with all attachments to:

New York State Department of Labor

Division of Labor Standards

Permit and Certificate Unit

State Office Campus

Building 12, Room 185B

Albany, NY 12240

F. Responsibilities (applicable to individual and group applicants)

•Within 60 days of the end of each calendar quarter, the PEO must submit a statement, signed by an independent CPA, certifying that there

is reasonable assurance that the firm has timely paid all applicable federal and state payroll taxes on all New York employees (for example: office, worksite, etc.) for that quarter and explaining the basis for this certification.

•Within 60 days of the end of each calendar quarter, a client list must be submitted, showing all changes since the last list submitted. Include the name and address, FEIN, type of business, and name of New York State Workers’ Compensation and Disability Insurance policyholders for each new client. The list should be signed by an officer, partner, owner or member, certifying the list is complete, current and accurate.

•Upon ending a contract, the client must be advised to contact the Unemployment Insurance (UI) Division concerning its UI liability. Inquiries can be directed to Liability and Determination Section, Unemployment Insurance Division, Department of Labor, State Campus, Albany, NY 12240. The telephone number is (518) 457-2635.

LS 665 (06/20)

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G. Declaration (to be completed by individual and group applicants)

By filing this request, the applicant authorizes the Unemployment Insurance Division to release the Unemployment Insurance records of the individual PEO, or PEO parent and each member of the group to the Division of Labor Standards.

I, the undersigned, affirm that I am an officer, partner, proprietor or member of the PEO, or the Applicant and Applicant Group, and am authorized to file this Request for Registration to operate as a PEO, or as a PEO Group, in the State of New York on its behalf or on behalf of the applicant PEO Group. I further affirm that the individual PEO, or PEO parent and each member of the group reviewed and will comply with all legal requirements of statues, in particular Article 31, the New York Professional Employer Act, and regulations of the Department of Labor. I affirm that the information in this request and all attachments is complete and accurate to the best of my knowledge.

Date

 

 

Signature of Chief Executive Officer, Partner,

 

 

 

 

Sole Proprietor or Member

 

 

 

 

 

 

 

 

Print name of above signatory

H. Group Guaranty (to be completed by each member of a PEO Group)

Each PEO that is a member of the PEO Group and is listed on this request must provide the following guaranty.

Guaranty

I, the undersigned, affirm that I am authorized to file this guaranty with the Department of Labor of the State of New York on

behalf of

 

[insert PEO name] (hereinafter Member Company).

Member Company is a PEO member of the

[insert name of applicant]

PEO Group and joins in the application for registration as a PEO group.

As part of this request, Member Company guarantees payment of all legal financial obligations of all other PEOs listed as members of the PEO Group in the request so long as they continue as members of the Group and under the common ownership and control of the applicant.

Date Signed

 

Signature of Chief Executive Officer, Partner,

 

 

Sole Proprietor or Member

Print name of above signatory

LS 665 (06/20)

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➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The New York LS 665 form is used for the registration of Professional Employer Organizations (PEOs) in New York State.
Governing Law This form is governed by Article 31 of the New York Labor Law, which outlines the legal framework for PEO operations.
Types of Requests Applicants can submit an initial request or a renewal request, either as an individual PEO or as part of a PEO Group.
Ownership Disclosure Applicants must disclose ownership information, including individuals or entities that hold a five percent or greater interest in the PEO.
Submission Deadline Initial applications must be submitted before operating in New York, while renewal applications are due within 180 days after the end of the PEO's fiscal year.
Financial Requirements A reviewed or audited financial statement is required, showing a minimum net worth of $75,000, prepared by an independent CPA.
Client List Confidentiality The list of New York clients submitted with the application will be kept confidential by the Department of Labor.

New York Ls 665: Usage Guidelines

Completing the New York LS 665 form is essential for registering a Professional Employer Organization (PEO) or a PEO group. This process requires careful attention to detail, as the information provided will determine eligibility and compliance with state regulations. Follow these steps to fill out the form accurately.

  1. Determine the type of request: On the first page, check the appropriate box for either "Initial" or "Renewal" for an individual PEO or a PEO Group.
  2. Fill in general information:
    • Provide the name of the individual PEO or parent organization.
    • List any additional business names.
    • Select the type of business organization from the options provided.
    • Enter the Federal Employer Identification Number (FEIN).
    • Complete the physical address of the Principal Administrative Office.
    • Provide a mailing address if it differs from the physical address.
    • Include the telephone, fax, and email address of the Principal Administrative Office.
    • List the current addresses of any additional offices in New York and any past offices maintained in the last five years.
    • Indicate the start and end dates of the fiscal year.
  3. Provide ownership information:
    • List all individuals or entities owning 5% or greater interest in the PEO or parent organization.
    • Include any past owners from the last five years who held a 5% or greater interest.
    • If publicly traded, list those owning 50% or greater interest.
  4. Complete group information (if applicable):
    • List all PEOs in the group, including their FEIN and addresses.
    • Provide any additional business names for the PEOs.
    • List addresses of additional offices maintained by group members and any past offices from the last five years.
  5. Prepare submission materials:
    • Attach necessary documentation, including corporate filing receipts and client contracts.
    • Include a list of all New York clients with required details.
    • Attach a reviewed or audited financial statement prepared by a CPA.
    • Provide proof of New York Workers’ Compensation and Disability Insurance.
  6. Sign the declaration: Ensure the request is signed by an authorized individual, affirming compliance with legal requirements.
  7. Mail the completed form: Send the form and all attachments to the specified address at the New York State Department of Labor.

After submitting the form, it is important to keep track of any correspondence from the Department of Labor. This may include requests for additional information or confirmation of registration. Ensure compliance with ongoing responsibilities, such as quarterly reporting and client list updates, to maintain good standing as a registered PEO in New York.

Your Questions, Answered

What is the purpose of the New York LS 665 form?

The New York LS 665 form is used for registering Professional Employer Organizations (PEOs) in New York State. This form is required for both initial registrations and renewals. It collects essential information about the PEO, including ownership details, business structure, and compliance with state labor laws.

Who needs to complete the LS 665 form?

Both individual PEOs and PEO groups must complete the LS 665 form. Individual PEOs refer to single entities, while PEO groups consist of two or more PEOs that are majority owned by the same organization. Each applicant must provide specific information as outlined in the form.

What information is required on the LS 665 form?

The form requires various details, including the name of the PEO or parent organization, type of business organization, Federal Employer Identification Number (FEIN), addresses, contact information, ownership information, and details about any additional offices in New York. Applicants must also provide financial statements and proof of insurance coverage.

How often must the LS 665 form be submitted?

Initial registration applications must be submitted before a PEO begins operations in New York. Renewal applications should be submitted within 180 days after the end of the PEO’s fiscal year. Regular updates, such as client lists and financial statements, are also required quarterly.

What are the financial requirements for submitting the LS 665 form?

Applicants must submit a reviewed or audited financial statement prepared by a certified public accountant (CPA) within 180 days prior to submission. This statement must demonstrate a minimum net worth of $75,000 and include a cover letter from the CPA certifying the financial position and tax compliance.

What insurance documentation is needed with the LS 665 form?

Applicants must provide proof of New York Workers’ Compensation and Disability Insurance. If the PEO has employees in New York, they must submit Form C-105.2 and DB-120.1. If there are no employees, Form CE-200 is required instead.

What happens if a PEO does not submit the LS 665 form on time?

Failure to submit the LS 665 form by the required deadlines can result in the inability to operate legally as a PEO in New York. This may lead to penalties, fines, or revocation of the ability to provide professional employer services.

Who is responsible for signing the LS 665 form?

The form must be signed by an authorized individual. For corporations, this is typically an officer authorized to bind the entity. For partnerships, sole proprietorships, or LLCs, the signature must come from a partner, owner, or member with binding authority.

Where should the completed LS 665 form be submitted?

The completed LS 665 form, along with all required attachments, must be mailed to the New York State Department of Labor, Division of Labor Standards, at the address specified in the form. This ensures that the application is processed correctly and efficiently.

Common mistakes

  1. Not marking the request type correctly: It's essential to indicate whether the application is for an initial registration or a renewal. Failing to check the right box can delay the process.

  2. Missing required addresses: Applicants often forget to provide the complete physical address of their principal administrative office. Ensure all addresses are accurate and up-to-date.

  3. Inaccurate ownership information: Listing all owners with a five percent or greater interest is crucial. Omitting any owners can lead to complications or rejection of the application.

  4. Neglecting to attach necessary documents: Applicants frequently overlook attaching required documents, such as the corporate filing receipt or proof of insurance. Double-check the submission checklist to avoid this mistake.

  5. Not signing the application: A common error is failing to have the application signed by an authorized individual. Ensure that the signature is from someone who can legally bind the organization.

  6. Submitting after deadlines: For renewal applications, it’s critical to submit within 180 days after the fiscal year ends. Missing this deadline can result in penalties or loss of registration.

Documents used along the form

When submitting the New York LS 665 form, several other documents may be required to ensure compliance with state regulations. Each of these documents serves a specific purpose in the registration process for Professional Employer Organizations (PEOs). Below is a list of commonly used forms and documents that accompany the LS 665 form.

  • Corporate Filing Receipt: This document confirms the legal formation of the PEO as a corporation in New York. It is essential for verifying the business's legitimacy.
  • Client Contract: A blank contract that outlines the terms of the relationship between the PEO and its clients. It must comply with Article 31 of the New York Labor Law.
  • Client List: A detailed list of all New York clients, including their names, addresses, and Federal Employer Identification Numbers (FEINs). This list is kept confidential and is crucial for compliance monitoring.
  • Financial Statement: An audited or reviewed financial statement prepared by an independent CPA. This document must demonstrate a minimum net worth of $75,000 and confirm timely payment of payroll taxes.
  • Workers' Compensation and Disability Insurance Proof: Evidence of coverage for New York State Workers' Compensation and Disability Insurance. This may include certificates of insurance or exemption forms.
  • Quarterly Tax Certification: A statement from a CPA certifying that all federal and state payroll taxes have been paid for the previous quarter. This document is required to maintain compliance.
  • Group Guaranty: A document signed by each member of a PEO Group, guaranteeing the financial obligations of all group members. This is necessary for group applications to ensure accountability.

These documents collectively support the application process and help ensure that the PEO operates in accordance with New York State laws. Proper preparation and submission of these forms can facilitate a smoother registration experience.

Similar forms

  • IRS Form 8832: This form is used to elect how an entity will be classified for federal tax purposes. Similar to the LS 665, it requires information about the organization’s structure and ownership.
  • New York State PEO Registration Application: This document is specifically for registering as a Professional Employer Organization in New York. Like the LS 665, it requires details about ownership, business structure, and operational locations.
  • Business License Application: This application is necessary for businesses to operate legally within a jurisdiction. Both the business license application and LS 665 require identification of the business type and owner information.
  • Form SS-4: This form is used to apply for an Employer Identification Number (EIN) from the IRS. Similar to the LS 665, it collects information about the entity’s structure and responsible parties.
  • New York State Workers' Compensation Insurance Application: This document is necessary for businesses that employ workers in New York. Like the LS 665, it requires detailed information about the organization and its operations.
  • Annual Report for Corporations: This report is filed by corporations to provide updated information to the state. Similar to the LS 665, it includes data on ownership and business activities.

Dos and Don'ts

When filling out the New York LS 665 form, it is important to adhere to certain guidelines to ensure a smooth application process. Below is a list of things to do and avoid.

  • Do: Clearly indicate whether the application is for an initial registration or a renewal on the first page.
  • Do: Provide accurate and complete information for all sections, including ownership details and addresses.
  • Do: Attach all required documents, such as financial statements and proof of insurance, as specified in the instructions.
  • Do: Sign the application with the appropriate authority, ensuring that the signer is authorized to represent the entity.
  • Don't: Leave any sections blank. Each section must be filled out to avoid delays.
  • Don't: Submit the application without the necessary attachments, as this could result in rejection.
  • Don't: Use outdated forms. Always ensure you are using the most current version of the LS 665 form.
  • Don't: Forget to double-check the accuracy of all information before submission, as errors can cause complications.

Misconceptions

Understanding the New York Ls 665 form is crucial for Professional Employer Organizations (PEOs) operating in the state. However, several misconceptions can lead to confusion. Here are ten common misconceptions along with clarifications:

  • Misconception 1: The Ls 665 form is only for new PEOs.

    • This form is required for both initial registrations and renewals. Existing PEOs must submit the renewal application within 180 days after the end of their fiscal year.

  • Misconception 2: Only individual PEOs need to register.

    • PEO groups, which consist of multiple PEOs under common ownership, must also complete the Ls 665 form to register as a group.

  • Misconception 3: The form does not require detailed ownership information.

    • Applicants must disclose all individuals or entities owning a significant interest in the PEO, whether privately held or publicly traded.

  • Misconception 4: Financial statements are optional.

    • Every initial application requires a reviewed or audited financial statement prepared by an independent CPA, demonstrating a minimum net worth of $75,000.

  • Misconception 5: Proof of insurance is not necessary if there are no employees in New York.

    • If a PEO has no office or internal employees in New York, they must still submit Form CE-200 to prove exemption from Workers’ Compensation and Disability Insurance.

  • Misconception 6: The application can be submitted without all required attachments.

    • All required documents, including client lists and proof of insurance, must accompany the application for it to be processed.

  • Misconception 7: The Ls 665 form can be submitted electronically.

    • Currently, the completed form and all attachments must be mailed to the specified address in Albany, NY.

  • Misconception 8: There is no need for a certification from a CPA after registration.

    • PEOs must submit quarterly certifications from a CPA to confirm timely payment of federal and state payroll taxes for all New York employees.

  • Misconception 9: The form does not require a signature from an authorized individual.

    • The form must be signed by an officer or authorized member of the PEO, affirming the accuracy of the information provided.

  • Misconception 10: The application process is quick and does not require follow-up.

    • After submission, applicants should be prepared for possible follow-up inquiries from the Department of Labor regarding any missing information or clarifications.

Key takeaways

When filling out and using the New York LS 665 form, it is essential to understand the following key points:

  • Type of Request: Clearly indicate whether your application is for an initial registration or a renewal. This distinction is crucial as it dictates the process you will follow.
  • General Information: Provide accurate details about your Professional Employer Organization (PEO), including its name, business structure, and contact information. This section establishes the foundation of your application.
  • Ownership Information: Disclose all individuals or entities that own a significant interest in your PEO. This transparency is vital for regulatory compliance and helps establish trust with the authorities.
  • Submission Instructions: Follow the specific guidelines for submitting your application, including required attachments such as financial statements and proof of insurance. Missing documentation can delay the processing of your application.

Understanding these points can streamline your application process and ensure compliance with New York State regulations.