New York Form Ls 665 PDF Details

Navigating the complexities of state regulations, Professional Employer Organizations (PEOs) in New York must adhere to specific registration requirements, as outlined in the New York LS 665 form. This detailed document serves as a comprehensive guide for both individual PEOs and PEO groups seeking initial registration or renewal of their status, ensuring compliance with the Division of Labor Standards. The form mandates the provision of general information about the PEO, including business type, office locations, and ownership details—information crucial for transparency and regulatory oversight. Additionally, it emphasizes the submission of financial statements that attest to the organization's fiscal health and its ability to meet financial obligations, including employee payroll taxes. Critical submissions also include proof of New York Workers’ Compensation and Disability Insurance, reflecting the state's commitment to worker protection. To streamline the registration process, the LS 665 form lays out specific submission instructions, alongside obligations for ongoing compliance and the procedures for guaranteeing financial responsibilities within PEO groups. Through mandates like these, New York ensures that Professional Employer Organizations operate with the highest standards of accountability and integrity, thereby safeguarding the interests of their client businesses and their employees.

QuestionAnswer
Form NameNew York Form Ls 665
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesLS665 peo registration application form ls 665 new york

Form Preview Example

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)

 

 

 

Page 1 of 4

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)

Page 2 of 4

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

For any questions, email PEOinfo.LS@labor.ny.gov 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)

Page 3 of 4

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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Fill in the New York Form Ls 665 PDF and enter the details for each area:

New York Form Ls 665 spaces to fill in

Write down the information in the b Mailing address if different, c Telephone fax and email address, Telephone Fax Email, a List the current address of each, Use separate sheet of paper if, b Other than those in a list the, Include any other names used and, Fiscal year starts, and ends, and Page of area.

step 2 to finishing New York Form Ls 665

The software will request you to put down some valuable details to easily submit the part Person or Entity, Ownership, Address, b List all persons not listed, Person or Entity, Ownership, Address, If the applicant PEO or its, f if ty percent or greater, Person or Entity, Ownership, Address, D Group Information to be, a List all the Professional, and Use additional paper if necessary.

stage 3 to completing New York Form Ls 665

The PEO, FEIN, Address, b Additional names if any under, a List the addresses of each, sheet of paper if necessary, b Other than those in a list the, and during the past five years Include area is where either side can put their rights and responsibilities.

New York Form Ls 665 PEO, FEIN, Address, b Additional names if any under, a List the addresses of each, sheet of paper if necessary, b Other than those in a list the, and during the past five years Include fields to complete

Finish by analyzing the next fields and completing them correspondingly: For any questions email, Make sure you have marked on the, Declaration and Group Guaranty if, With an initial request submit a, State Secretary of State for each, The statement must have been, o o Where the Group or the Groups, schedules covering each, Attach proof of New York Workers, If you have office and internal, If a corporation the request must, and Mail the completed request with.

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