Form LB-0441 – Fill Out and Use This PDF

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

REPORT TO DETERMINE STATUS

RETURN TO: EMPLOYER SERVICES - STATUS/RATES

TN DEPT OF LABOR AND WORKFORCE DEV

APPLICATION FOR EMPLOYER NUMBER

220 FRENCH LANDING DRIVE

NASHVILLE TN 37243-1002

OFFICIAL USE ONLY

(615) 741-2486

FAX (615) 741-7214

1. Enter Federal Number, Business Name and Address

Tennessee ID#

M. No.

SIC

County

Area

Federal Number

___ ___ - ___ ___ ___ ___ ___ ___ ___

Liab. Org. First Employment

Date Liable

Rate

Employer Name

_______________________________________

_______________________________________

Comp Year

NAICS

M-NAICS

M-SIC

Trade Name

_______________________________________

_______________________________________

Previous No.

ROC

AUX-SIC

VERIFIED

Mailing Address

_______________________________________

_______________________________________

_______________________________________

PHYSICAL BUSINESS ADDRESS in Tennessee if different from above:		PHONE: ( _______ ) ___________________
_______________________________________________________		FAX: ( _______ ) ______________________
_______________________________________________________		E-MAIL ADDRESS: _____________________________
2. Is your organization a Professional Employer Organization (PEO)?	YES	NO	If Yes, Tennessee license number __________________
Is your organization a client of a Professional Employer Organization (PEO)?	YES	NO

3. CHECK (X) FORM OF ORGANIZATION 4. Name of Owner, Partners, Corporate Officers		Social Security Number		Residential Address
	Limited Liability Company Members and Managers				and Phone
	(If Board Managed), General Partners
	(Attach separate sheet if necessary)
INDIVIDUAL
PARTNERSHIP
CORPORATION
LIMITED LIABILITY COMPANY
LIMITED PARTNERSHIP
OTHER
NOTE: If a Limited Liability Company, are you treated by IRS as a(n) Individual Proprietorship			Partnership or as a		Corporation
5. Name of person responsible for payroll records _____________________________________			Phone Number _______________________

7.REGULAR BUSINESS EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)

A. Have you employed or do you expect to employ at least one worker in twenty different calendar weeks during a calendar year? YES				NO
If Yes, give earliest month and year the twentieth week occurred (will occur). MONTH ______________________			YEAR _______________
B. Have you had or do you expect to have a quarterly payroll of $1,500 or more? YES	NO
If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________		YEAR ____________________

8.HOUSEHOLD EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)

A. Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? YES	NO
If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________	YEAR _______________

9.AGRICULTURAL EMPLOYMENT (SEPARATE REPORTS MUST BE FILED FOR EACH CALENDAR QUARTER IN WHICH WAGES WERE PAID.)

A. Have you employed or do you expect to employ at least ten or more workers in some part of a day in twenty different weeks during a calendar year?

YES	NO	If Yes, give earliest month and year this occurred (will occur). MONTH ______________________		YEAR ______________
B. Have you had or do you expect to have a quarterly payroll of $20,000 or more? YES			NO

If Yes, give earliest quarter and year this occurred (will occur). QUARTER ______________________ YEAR _______________

If you answer Yes to any one of the questions 6D, 7, 8, 9, or 10F, you are liable for unemployment insurance premiums based on the first $9,000 paid

each employee per year.
Have you previously had an account with this department? YES	NO	Account Number ____________________________
Signature ____________________________________	Title _________________________		Date	________________________/	/

Must be owner, partner, authorized limited liability company member or manager, or officer of the corporation.

PLEASE COMPLETE PAGE 2. FAILURE TO DO SO WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.

LB-0441 (Rev 07-13)

RDA 1559

10. (A) Name and Address of predecessor employer	_______________________________________________________
	_______________________________________________________
	_______________________________________________________

(B)	Account Number of predecessor employer _____________________		(C)	Date of acquisition _____/_____/_____
(D)	Did you acquire all of your predecessor’s business in Tennessee? YES		NO	If No, what percentage did you acquire? _____
(E)	Did your predecessor continue in business in Tennessee?	YES	NO

(F)Tennessee Employment Security Law provides for the mandatory transfer of an employer’s benefit and premium experience whenever there is any common ownership, management or control between the predecessor and successor employers.

Did any owner or manager of this company have an ownership interest in or participate in the management or control of the

business acquired?YESNO

If “YES,” please explain: __________________________________________________________________________________

Per TCA 50-7-403(b)(2)(C)(ii) “Common ownership, management or control” includes any individual who has at least a 10% ownership interest in - or who participates in the management or control of - the predecessor’s trade or business and has a relative with a 10% ownership interest in - or who participates in the management or control of - the successor’s trade or business.

Does anyone who had a 10% or more ownership interest in the previous company - or who participated in its management or control - have a relative with a 10% or more interest in this company or who participates in its management or control?

YES NO If “YES,” please explain: __________________________________________________________________

If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483, Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which the acquisition occurred.

11. Enter below the amount of total payroll for each quarter in which you have had or expect to have employment.

NOTE: If your organization is exempt from Federal Income Taxes under Section 501(C) (3) of the IRS Code, attach a copy of letter of exemption.

Non-profit public, and/or governmental organizations are not exempt from state unemployment insurance, unless certain requirements are met. If you are unsure about your present or future unemployment insurance status, please contact us for assistance at (615)741-2486.

12.FAILURE TO PROPERLY COMPLETE THIS SECTION WILL RESULT IN RECEIVING THE HIGHEST PREMIUM RATE ASSIGNABLE.

Briefly describe the major business activity of the account to be covered, listing any products produced or sold, or service provided. Be as descriptive as possible. _____________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

In what Tennessee County is your company located? ________________________________________________________

(If account covers sales reps or other personnel working from home, list county of residence. If county is unknown, list city of residence.)

For the work location covered by this application, is the main activity to: (Check one) Supply products and services to the general public or other companies

Support other locations of your company (if you check this, please specify below)

HEADQUARTERS (e.g. : Corporate or regional management offices)

ADMINISTRATIVE, OTHER THAN HEADQUARTERS (e.g.: data processing, public relations)

RESEARCH (e.g.: R & D, product testing, laboratory)

STORAGE (e.g.: warehouse, distribution center, equipment yard)

OTHER (please describe) (e.g.: Repair shop, security office, maintenance, employee recreation facility)

Please check the box describing your company’s major business activity:

Agriculture, Forestry, Fishing and Hunting	Real Estate and Rental and Leasing
Mining	Professional, Scientific, Technical Services
Utilities	Management of Companies and Enterprises
Construction	Administrative and Support and Waste Management
Manufacturing	and Remediation Services
Wholesale Trade	Educational Services
Retail Trade	Health Care and Social Assistance
Transportation and Warehousing	Arts, Entertainment and Recreation
Information	Accommodation and Food Services
Finance and Insurance	Other Services (except Public Administration)
	Public Administration

LB-0441 (Rev. 07-13)

RDA 1559

INFORMATION FOR COMPLETING STATUS APPLICATION

Enclosed is a Report to Determine Status/Application for Employer Number. The Tennessee Employment Security Law and Regulations requires each employing unit in Tennessee to file this report with the Department of Labor and Workforce Development for the purpose of determining status. If you answer “Yes” to question 6(d) or any one of the questions in items 7, 8 or 9 on the status application, you are liable for unemployment insurance coverage with this department. Please complete and submit the enclosed form as soon as you have paid wages for services performed in Tennessee.

The requirements for liability are:

REGULAR BUSINESS EMPLOYERS

Items 7 A and B on the status application do not pertain to farm or household employees.

Item 7A. During some part of a day in each of twenty calendar weeks of a calendar year, did you employ or do you expect to employ one or more persons? (The weeks need not be consecutive and both full and part-time workers are counted.)

OR

Item 7B. Have you paid or do you expect to pay wages of $1,500 or more in any calendar quarter?

HOUSEHOLD EMPLOYERS

Item 8. Did you have or do you expect to have a calendar quarter in which you paid household employee(s) $1,000 or more in cash wages? If so, you are liable for all wages paid during that year and the following calendar year.

AGRICULTURAL EMPLOYERS

Item 9A. During some part of a day in each of twenty weeks of a calendar year did you employ or do you expect to employ ten or more persons? (The weeks need not be consecutive and both full and part-time workers are counted.)

OR

Item 9B. Have you paid or do you expect to pay wages of $20,000 or more in any calendar quarter?

Leave the space under Item 1 for Federal Number blank if you have not yet been assigned a FEIN (Federal Employer Identification Number). You will receive a letter asking for this number after we establish your state account. Return the letter with your FEIN when you receive the number from the Internal Revenue Service.

If you are completing quarterly reports and/or the Application for Transfer of Experience Rating (LB-0483), please return them in the same envelope with this application. DO NOT write in the box titled State Account Number if you are submitting quarterly Premium (LB-0456) and Wage (LB-0851) Reports along with this application. Your new number will be recorded here when assigned.

Anyone who is paid for personal services by a corporation is considered to be an employee of the corporation even if that person is an officer and/or owns stock in the corporation.

NOTE: PLEASE BE SURE TO SIGN YOUR STATUS APPLICATION at the bottom and include the appropriate information. Also, complete both pages of your Status Application form.

Failure to complete both pages of the application or to provide sufficient information upon which to correctly classify the industry code will result in the highest new employer rate being assigned.

LB-0441 (Revised 04-11)

RDA 1559

Mail To: Employer Services - Status/Rates

TN Dept of Labor and Workforce Development

220 French Landing Drive

Nashville TN 37243-1002

PREMIUM RATE INFORMATION

New employers in Tennessee are initially subject to a “new employer” rate until their account has been subject to premiums and chargeable with benefits for thirty-six consecutive months ending on the computation date (December 31 of each year). They then become eligible, beginning on the next July 1, for a premium rate based on their individual reserve experience.

New employer rates are determined separately for each major industry group based on the combined reserve experience of each industry group as a whole. Presently, all industries, except construction, mining, and manufacturing have a new employer rate of 2.7%. The new employer rates for construction, mining, and manufacturing are listed below.

Rate Year		Construction		Mining			Manufacturing
						Sector 31		Sector 32		Sector 33
July ‘06 - June ‘07		6.0%		7.5%		6.0%		2.7%		6.0%
July ‘07 - June ‘08		5.0%		6.5%		6.0%		2.7%		6.0%
July ‘08 - Dec ‘08		5.0%		6.0%		5.5%		2.7%		6.0%
Jan ‘09 - June ‘09		5.6%		6.6%		6.1%		2.7%		6.6%
July ‘09 - June ‘10		6.1%		6.6%		5.6%		2.7%		7.1%
July ‘10 - June ‘11		8.1%		8.6%		5.6%		6.6%		9.1%
July ‘11 - June ‘12		8.6%		6.6%		2.7%		6.6%		9.1%
July ‘12 - June ‘13		8.6%		6.1%		2.7%		6.1%		8.6%

NAICS Manufacturing Sector 31 includes food, beverage, and tobacco products, as well as textiles, leather, and apparel products.

NAICS Manufacturing Sector 32 includes wood products, paper products, printing and related support activities, petroleum and coal products, chemical manufacturing, plastics and rubber products, and nonmetallic mineral products.

NAICS Manufacturing Sector 33 includes metal products, machinery, computer and electronic products, electrical equipment, appliances, transportation equipment, and furniture manufacturing.

Taxable wages are the first $9,000 of gross wages paid to each employee per year.

LB-0441 (Revised 09-12)

RDA 1559