
C-1BK (091415) Page 2 of 2
Domestic - Household Employment Section
Complete 22 only if you have domestic or household employees (includes maids, cooks, chauffeurs, gardeners, etc.)
22. Enter the ending date of the first calendar quarter in which you paid gross wages of $1,000 or more to employees
performing domestic service:
Nature of Activity Section
23. Describe fully the nature of activity in Texas, and list the principal products or services in order of importance:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
24. If the business in Texas was acquired from another legal entity, you must complete items 24-26. If a partial acquisition occurred, the predecessor/successor may jointly
submit information regarding a partial transfer of experience.
a) Previous owner’s TWC Account Number (if known) ______________________________________________________________________________
b) Date of acquisition _________________________________________________________________________________________________________
c) Name of previous owner(s) _________________________________________________________________________________________________
d) Address ________________________________________________________________________________________________________________
e) City _______________________ State __________________________ Zip _________________________________
What portion of business was acquired? (check one) all part (specify)
25. On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to any
of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or
equitable interest in the successor business? Yes No
If “Yes”, check all that apply: same owner, officer, partner, or shareholder sole proprietor incorporating
same parent company other (describe below)
_________________________________________________
If “No,” on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to any of
these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor business?
yes no
26. After the acquisition, did the predecessor continue to:
• Own or manage the organization that conducts the organization, trade or business?
• Own or manage the assets necessary to conduct the organization, trade or business?
• Control through security or lease arrangement the assets necessary to conduct the organization, trade or business?
• Direct the internal affairs or conduct of the organization, trade or business?
Yes No
If “Yes” to any of above, describe: _____________________________________________________________________________________________
Voluntary Election Section
27. A non-liable employer may elect to pay state unemployment tax voluntarily. If an employer elects to do so, the employer is obliged to pay taxes for a minimum of two
calendar years, beginning with January 1 of the first year of the election. The employer may withdraw the election by written request, at the end of the 2-year period,
if not yet liable under the Texas Unemployment Compensation Act. To elect this option, complete the following:
Yes, effective Jan. 1, I wish to cover all employees (except those performing service(s) which are specifically exempt in the Texas Unemployment
Compensation Act).
I hereby certify that the preceding information is true and correct, and that I am authorized to execute this Status Report on behalf of the employing unit named herein.
(this report must be signed by the owner, officer, partner or individual with a valid Written Authorization on file with the Texas Workforce Commission)
Month ___ Day ___ Year ___
Sign here ________________________________________
Title _______________
Driver's license number __________________ State __________ E-mail address ______________________________________________
Individuals may receive, review and correct information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to: TWC Open
Records, 101 E. 15
th
St., Rm. 266, Austin, TX 78778-0001.