New York Form Ls 665 – Fill Out and Use

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.

E. Submission Instructions (Applicable to Individual and Group Applicants)

For any questions, email PEOinfo@labor.state.ny.us or call (518) 457-1942. Submit 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;

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.

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.

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

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:

If 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).

If 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.state.ny.us Click”on “WC/DB Exemptions”. Then click “”Request for WC/DB Exemptions.”

Attach a check for the correct amount made payable to Commissioner of Labor as follows:

$1,000.00 initial fee for each individual PEO. For a PEO group, include $1,000.00 for the parent organization and $1,000.00 for each member of the group.

$500.00 renewal fee for each individual PEO. For a PEO group, include $500 for the parent group and $500.00 for each member of the group.

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, Room 266A

State Office Campus, Building 12

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.