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GEORGIA DEPARTMENT OF LABOR

SUITE 850 - 148 ANDREW YOUNG INTERNATIONAL BLVD NE - ATLANTA, GA 30303-1751

EMPLOYER STATUS REPORT

READ INSTRUCTIONS ON REVERSE SIDE

BEFORE COMPLETION OF FORM

1.ENTER OR CORRECT BUSINESS NAME AND ADDRESS

RETURN ORIGINAL WITHIN 10 DAYS

GEORGIA DOL

ACCOUNT NUMBER

(If already assigned)

3. TRADE NAME

2. TYPE OF ORGANIZATION

Individual

Partnership

Corporation

Nonprofit org.

4. PRINCIPAL BUSINESS,

Street Address

Limited Liability CO. (LLC)

FARM OR

HOUSEHOLD

Other (specify)

LOCATION IN

GEORGIA

City

Zip Code

County

Telephone Number

(Do not use a

(

)

P. O. Box number)

5. DATE FIRST BEGAN

DATE OF

6. ARE YOU LIABLE

Yes

FEDERAL

EMPLOYING WORKERS

FIRST GA.

FOR FEDERAL

I.D.

WITHIN STATE OF GA.

PAYROLL

UNEMPLOYMENT TAX?

NUMBER

7. HAVE YOU...

DATE ACQUIRED

DID YOU ACQUIRE...

OR CHANGED

Acquired another business?

Yes

All of Georgia operations?

PREDECESSOR’S

Merged with another business?

Yes

GEORGIA DOL

Substantially all of Georgia operations

ACCOUNT NUMBER

(90% or more)

DOES THE FORMER OWNER

Part of Georgia operations (less than 90%)

CONTINUE TO

Formed a corporation or

Yes

HAVE EMPLOYEES?

partnership?

Yes

Made any other change in the

ownership of your business?

Yes

If yes, explain

FROM WHOM? (Organization name, including trade name)

ADDRESS

8. IF YOU HAD PRIVATE BUSINESS EMPLOYMENT:

9. IF YOU HAD DOMESTIC EMPLOYMENT:

Did you, or do you expect to employ at least one worker

Did you, or do you expect to pay cash wages

of $1,000 or more in any calendar quarter?

Yes*

in 20 different calendar weeks during a calendar year?

Yes *

* If yes, show date the 20th week first occurred:

* If yes, show date this first occurred:

10. IF YOU HAD AGRICULTURAL EMPLOYMENT:

Yes*

Did you, or do you expect to have a

Did you, or do you expect to employ 10 or more agricultural

quarterly payroll of $1,500 or more?

Yes *

workers in 20 different calendar weeks during a calendar year?

* If yes, show date this first occurred:

* If yes, show date the 20th week first occurred:

11. IF YOU ARE A NONPROFIT ORGANIZATION EXEMPT

Did you, or do you expect to have a gross cash agricultural

FROM INCOME TAX UNDER IRS CODE 501(C)(3):

Yes *

payroll of $20,000 or more in any calendar quarter?

Yes*

Did you, or do you expect to employ four or more

* If yes, show date this first occurred:

workers in 20 different calendar weeks during a

calendar year? (ATTACH COPY OF 501(C)(3) EXEMPTION LETTER)

12. HOW MANY EMPLOYEES do you have, (or anticipate

* If yes, show date the 20th week first occurred:

when in full operation)?

Name

INFORMATION

ABOUT

OWNER,

Social Security

PERSON

Number

OR FIRM

Address

ALL

WHO

PARTNERS,

MAINTAINS

Residence Address

OR PRINCIPAL

FINANCIAL

City

OFFICER

RECORDS

(ATTACH

OF BUSINESS

City

ADDITIONAL

State

Zip Code

Telephone

SHEET,OR

(

)

SHEETS, IF

State

Zip Code

CERTIFICATION: I hereby certify under penalties of perjury, that the foregoing statement and those contained

NECESSARY)

in any attached sheets signed by me are true and correct, and that I am authorized to execute this report on

behalf of the employing unit. This report must be signed by owner, partner or principal officer.

Telephone

Signature

Title

Date

( )

PLEASE COMPLETE INDUSTRY INFORMATION ON REVERSE SIDE.

DOL-1A (R-5/05)

TA489A

(CONTINUED)

NATURE OF BUSINESS: Information is required on all items. Attach additional sheets, if necessary.

A. How many Georgia locations do you operate?

C. Enter in order of importance and indicate

Provide the following information for each location, attaching additional

approximate % of total annual income derived

sheets if necessary.

from each:

B. Check the box that best describes the industry that relates to your

Principal Service(s)

Principal Product(s)

business activities:

Rendered*

Mfg.

Grown

Sold

Agriculture

Manufacturing

Forestry

Transportation

Fishing

Communication

* If Transportation - Trucking, indicate if interstate carrier

Mining

Public Utilities

Construction (specify):

Wholesale Trade

General Contractors Industrial

Retail Trade

D. If this report includes establishment(s) that only

Residential

% Commercial

Finance

perform services for other units of the company,

Speculative Building

Insurance

indicate the primary type of service or support

Special Trade Contractor (specify plumbing,

Real Estate

provided. Check as many as apply:

etc.,)

Services

Central Administration

Storage (warehouse)

Heavy Construction (specify cable, highway,

Public Administration

etc.,)

Private Household

Research, development,

Other: (specify)

and testing

Employer

FOR ASSISTANCE, call the Industry Classification Unit, (800) 338-2082

IMPORTANT - This report must be filed! The law provides that all employing units shall file a report of its employment during a calendar year. For the purpose of aiding you in complying with OCGA Section 34-8-121 of the Employment Security law, this form has been prepared to assist you in furnishing the required information. Answer all questions fully and if additional space is necessary under any item, attach signed and dated sheets which bear the words Supplement to Form DOL-1.”

Each false statement or willful failure to furnish this report is punishable as a crime. Each day of such failure or refusal constitutes a separate offense.

The Georgia Employer Status Report is required of all employers having individuals performing services in Georgia regardless of number or duration of time.

The filing of this form is required at the time your business first had individuals performing service in Georgia, or when you acquired another legal entity, and may also be required again upon request.

NOTE: Disclosure of your social security number is mandatory. It will be used for the purpose of identification and it is required under the authority of 42 U.S.C. Section 405(2)(c) and OCGA Section 34-8-121(a).

INSTRUCTIONS

(NUMBERS CORRESPOND TO ITEMS ON FORM)

1.Enter or correct name and address of individual owner, partners, corporation or organization. This is the address to which you authorize us to mail all reports, correspondence, etc. If you have already been assigned a Georgia Department of Labor Account Number (Ga. DOL Acct. No) by this Department, please insert the number.

2.Indicate by check mark type of organization. If a nonprofit organization, attach copy of I.R.S. letter exempting the organization from Federal Income Tax under Section 501(c)(3)of Internal Revenue Code.

3.Trade name by which business is known if different than 1.

4.Physical location of business, farm or household in Georgia if different than 1. Please include telephone number with area code.

5.Enter the first date of employment in Georgia and the first date of Georgia payroll.

6.If you are subject to the Federal Unemployment Tax Act, and are required to file Federal Form 940, answer this question “yes”. Be sure to enter your Federal Employer Identification Number whether answered “yes” or “no”.

7.Answer this question if you acquired this business from another employer or if after you began employing workers you have acquired other busi- nesses; merged with other businesses; formed or dissolved partnerships, corporations, professional associations; or if any other change in the ownership of the business has occurred. Indicate the date of acquisition or change and provide all information concerning the previous owner’s name, trade name, address and DOL Account Number. Indicate by checking the appropriate block the portion of the previous owner’s business involved in the acquisition or change. No transfer of experience rating history can be made unless information concerning the previous owner is provided.

8.Private Business Employment - Most employment is considered private business employment. This includes all types of work except domestic service such as maids, gardeners, cooks, etc., agricultural service and service performed for governmental or nonprofit organizations.

9.Domestic employment includes all service for a person in the operation and maintenance of a private household, local college club or local chapter of a college fraternity or sorority such as chauffeurs, cooks, babysitters, gardeners, maids, butlers, private and/or social secretaries, etc. If you had such employment, consider only cash payments made to all individuals performing domestic services to determine if $1,000 or more cash wages were paid in any calendar quarter during 1977 and subsequent quarters.

10.Consider only cash payments made to all individuals performing agricultural services to determine if $20,000 or more cash wages were paid in any calendar quarter during 1977 and subsequent quarters.

11.Answer this question only if this business is a nonprofit organization exempt from Federal Income Tax under Section 501(c)(3) of the Internal Revenue Code. Attach a copy of the I.R.S. letter granting this exemption. Nonprofit organizations with tax exemptions other than under Section 501(c)(3) should answer question 8, Private Business Employment.

12.Self-explanatory.

FOR ASSISTANCE, call the Adjudication Section, (404) 232-3301.

Please RETAIN a copy for your files.	RETURN ORIGINAL WITHIN TEN (10) DAYS TO:	Georgia Department of Labor
		P. O. Box 740234
The enclosed envelope requires postage.		Atlanta, GA 30374-0234

Question	Answer
Form Name	Dol 1A Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	SHEETOR, DOL-1, exempting, R-5

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