Sfn 41216 Form PDF Details

Understanding the intricacies of the SFN 41216 form is crucial for businesses operating within North Dakota. This form, designated for Job Service North Dakota, plays a vital role in determining a business's liability under unemployment insurance statutes. Essentially, it is a comprehensive document that collects detailed information about a business, including but not limited to, the business name, corporate or legal name, Federal Employer ID (FEIN), addresses, and the type of ownership. The form also delves into whether the business has employed workers in North Dakota, which is a critical factor for unemployment insurance. Additionally, it addresses situations such as acquiring assets or businesses of another employer and changes in business status or structure. For nonprofit organizations, specific sections need to be completed to align with their exempt status. Moreover, the form inquires about the employment of nontraditional workers, such as those in temporary or leased employment arrangements, and requires a description of the business's activities in North Dakota. With a section dedicated to government entities, Indian tribes, or wholly-owned entities of an Indian tribe, it ensures all types of organizations can accurately report their status. Completing the SFN 41216 form accurately is essential for ensuring compliance with North Dakota's unemployment insurance laws, making it an indispensable tool for businesses within the state.

QuestionAnswer
Form NameSfn 41216 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnorth dakota form 41216, nd form sfn11106, north dakota sfn report, north dakota report determine

Form Preview Example

REPORT TO DETERMINE LIABILITY

Job Service Use

 

JOB SERVICE NORTH DAKOTA

 

 

 

EAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNEMPLOYMENT INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ST

 

 

 

 

 

 

 

SFN 41216 (R. 8-2019)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BY

 

 

FR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UI TAX AND FIELD SERVICES

 

 

 

RA

 

YR

 

-1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO BOX 5507

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-2

 

Q

STF

 

BISMARCK NORTH DAKOTA 58506- 5507

 

 

 

 

 

 

 

 

 

 

 

701-328-2814 FAX: 701-328-1882 TTY RELAY ND 800-366-6888

 

SIC

 

 

AUX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAIC

 

 

AUX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Web link to: NEW BUSINESS REGISTRATIONS IN NORTH DAKOTA

 

LOC

 

 

OWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Business Name

 

 

 

 

 

 

 

 

 

3. Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Corporate or Legal Name

 

 

 

 

 

 

 

 

 

4. Federal Employer ID (FEIN)

 

 

 

 

 

 

 

 

 

 

 

5. Mail Address (Number and Street or P.O. Box)

 

City

 

 

 

State

ZIP Code + 4

Internet Address (optional)

 

 

 

 

 

 

 

 

 

 

 

 

6. Street Address (Number and Street)

 

 

City

 

 

 

State

ZIP Code + 4

E-mail Address (optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Is (Are) any other business(es) being operated

 

 

If yes, Name of Business(es)

 

 

 

 

 

 

 

 

 

in North Dakota by this ownership?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Type of Ownership

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual

 

 

 

Partnership (Indicate type: general, LP, LLP, etc.)

 

 

 

 

 

 

 

 

 

Corporation Click to obtainSFN 18411

 

 

 

Limited Liability Company (LLC) (Indicate treatment for federal income taxreporting):

 

if you wish to exempt Corp Officer services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nonprofit Corporation

 

 

 

Disregarded Entity

Partnership

Corporation

S-Corp

Don't Know

 

Government

 

 

 

Cooperative

 

 

 

 

 

 

 

 

 

 

 

Indian Tribe or Wholly-Owned

 

 

 

Other (Describe)

 

 

 

 

 

 

 

 

 

 

 

Entity of an Indian Tribe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In what state was your business originally incorporated/registered?

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. List the owner(s) and all partners or corporate officers. Also, any corporate director or employee having a 20 percent or more ownership

interest. Attach separate sheet if necessary.

 

 

Social Security

Percent

 

 

 

 

Name

Home Address

Title

Number*

Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility purposes and program performance accountability.

10. Have you employed workers in North Dakota?

If yes, date you first employed workers in North Dakota

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are a government entity, Indian tribe, or wholly-owned entity of an Indian tribe, go to Question 17.

11. Did you acquire any part of the ND assets or business of another employer or change your business status/structure in any way?

Yes

No If yes, complete Schedule B.

12. Are you liable for federal unemployment taxes (FUTA)?

Yes

No

Don't Know

If yes, go to Question 18. You will be covered under North Dakota law as of the first day you

employ workers in this state.

 

SFN 41216 (1-2013)

Page 2 of 4

13. Are you a nonprofit organization exempt from income taxes under Section 501(c)(3), IRS Code?

Yes

No - Go to #14

Applied For - Go to #14

If yes, complete this section and submit a copy of your exemption letter from the IRS to Job Service North Dakota. You need not complete sections 14 and 15.

As a nonprofit organization, have you employed four or more persons during 20 weeks of any calendar year in any state?

Yes

No - Go to #16 If yes, date the 20th week was first reached.

When answering Questions 14 and 15, include as employees all part-time workers and non-exempt (see Employer's Guide) corporate officers and limited liability company managers. Do not include spouse, children under 18 who live at home, or parents of an individualowner

-this does not apply to corporations or limited liability companies. This exclusion applies to partnerships only if the worker has an exempting relationship with each partner.

14. Enter the amount of wages you have paid in North Dakota (do not estimate or include wages earned but not paid):

 

Jan. 1 to March 31

April 1 to June 30

July 1 to Sept. 30

Oct. 1 to Dec. 31

 

 

 

 

 

Current

 

 

 

 

Year

$

$

$

$

Preceding

$

$

$

$

Year

 

 

 

 

Prior

$

$

$

$

Year

 

 

 

 

Year

$

$

$

$

15. During the 20 weeks of any calendar year, have you employed:

a.

One or more persons in general employment?

 

Yes

 

 

 

 

Yes

 

 

 

b.

Ten or more persons in agricultural employment?

 

 

 

 

 

If yes, date the 20th week was first reached.

No

No

16.If it is determined that you are not now liable for coverage, do you want to become covered voluntarily? See NDCC 52-05-03(2) for voluntary coverage information.

Voluntary coverage is not available if you answered no to question #10

Yes

No

17.Complete this section only if you are a governmental entity, Indian tribe or wholly-owned entity of an Indian tribe, or a 501(c)(3) tax exempt organization and answered yes to either Question 13 or 16.

Select one of the following benefit financing options: (see NDCC 52-04-18 for benefit financing methods)

Reimbursement of benefit payments attributable to employment with your organization.

Payment of taxes on your quarterly taxable payroll at the rate applicable for new employers.

Advanced reimbursements at a percent of your quarterly total payroll to be redetermined annually.

Will default to Payment of Taxes: 1) if not completed and/or 2) if you have not provided an IRS exemption letter.

18. Have any individuals you do not consider employees performed services for you in North Dakota?

 

Yes

 

No

 

 

 

 

 

If yes, give reasons for excluding them and indicate number of persons involved.

 

 

 

 

 

 

 

 

19.

Does any part of your business activity include the provision of "temporary" or "leased" workers to a client company?

 

Yes

 

No

 

 

 

 

 

 

20.

Give a specific description of your business activity in North Dakota.

 

 

 

 

Enter on separate lines the principal product or activities of your firm. Following each item, list the percentage of sales value or receipts received from the product or activity; i.e., retail men's clothing, electrical construction-residential, or long haul trucking-refrigerated van.

%

%

%

%

SFN 41216 (1-2013)

Page 3 of 4

21.Business Locations: Enter the North Dakota addresses from which your employees work and indicate if the location is permanent or temporary. If you do not maintain an office in North Dakota, enter the employee's address.

Address

City

State ZIP Code

Telephone

Permanent Temporary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Remarks:

22.

Name of Authorized Representative

Title

Telephone Number

Fax Number

 

 

 

 

Name of Individual Completing Form

Title

Telephone Number

Date

I certify the information on SFN 41216, Report to Determine Liability, is true and accurate.

Job Service is an equal opportunity employer/program provider.

Auxiliary aids and services are available upon request to individuals with disabilities.

REPORT TO DETERMINE LIABILITY

Complete Schedule B only if you answered “yes” to question 11 on

SCHEDULE B - SUCCESSORSHIP QUESTIONNAIRE

form SFN 41216, Report to Determine Liability

Successorship Reporting Requirement. If you acquired all or part of the organization, business, trade, or assets of another employer and will continue essentially the same business activity, you must provide the following information. If you made multiple acquisitions, you must file a separate Schedule B for each acquisition. Submit the completed Schedule B(s) along with Form SFN 41216, Report to Determine Liability, to Job Service North Dakota.

PART 1: CURRENT/NEW OWNER INFORMATION

Name

UI Account Number

 

 

Federal Employer Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 2: FORMER OWNER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Owner's Name (required)

 

 

Former Owner's UI Number or FEIN, if known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corporate Name or DBA

 

 

 

 

 

 

 

 

 

 

Area Code and Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Street Address (not a P.O. Box)

 

 

City

 

 

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 3: ACQUISITION INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percent Acquired

Date Acquired

1.

Did you acquire all, part or none of the former owner's assets?

 

 

All

 

Part

 

 

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percent Acquired

Date Acquired

2.

Did you acquire all, part or none of the former owner's workforce?

 

 

All

 

Part

 

 

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Did you acquire all, part or none of the former owner's North

 

 

 

 

 

 

 

 

 

Percent Acquired

Date Acquired

 

 

All

 

Part

 

 

None

 

 

 

 

Dakota trade (customers/accounts)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Did you acquire all, part or none of the former owner's North

 

 

 

 

 

 

 

 

 

Percent Acquired

Date Acquired

 

 

All

 

Part

 

 

None

 

 

 

 

Dakota business (products/services)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Was the North Dakota business being operated at the time of the

 

 

 

 

 

 

 

 

 

 

 

Date (MM, DD, YYYY)

 

 

Yes

 

No

 

 

 

 

 

 

 

acquisition? If no, enter the date it was closed by the former owner.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Are you continuing the North Dakota business you acquired?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Is your North Dakota business substantially owned or controlled in

 

 

 

 

 

 

 

 

 

 

 

 

 

any way by the same interests that owned or controlled the former

 

 

Yes

 

No

 

 

 

 

 

 

 

business?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Will the previous business/account continue in business in North

 

 

Yes

 

No

 

 

 

Don't Know

 

 

 

 

 

 

 

 

 

Dakota?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

If eligible, do you wish to continue the experience rating established

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

by the acquired/previous business?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do and are assigned your predecessor's tax rate, your new account will also be chargeable for any benefits payable to your

 

predecessor's workers.

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not answer this question and it is determined that you are a liable employer, you will receive the rate normally assigned to new employers; it will

 

not include the predecessor's history.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NDCC 52-04-08.2 provides for penalties in cases where the acquisition of a business is solely or primarily for the purpose of obtaining a lower unemployment insurance tax rate. Criminal and/or civil penalties apply.

Name of Owner/Officer

Title

Telephone Number

Date

I certify the information on SFN 41216, Schedule B, is true and accurate.

Go to the bottom of page 3 to submit the form.

Notice: Wage and other confidential information collected from employers as part of the unemployment insurance process may be requested and utilized for other governmental purposes, including, but not limited to, verification of eligibility under other government programs as required by law.

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2. Once your current task is complete, take the next step – fill out all of these fields - Individual, Corporation Click to obtain SFN, if you wish to exempt Corp Officer, Nonprofit Corporation, Partnership Indicate type general, Limited Liability Company LLC, Disregarded Entity, Partnership, Corporation, SCorp, Dont Know, Government, Indian Tribe or WhollyOwned Entity, Cooperative, and Other Describe with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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4. The subsequent section will require your information in the subsequent areas: Are you a nonprofit organization, Yes, No Go to, Applied For Go to, If yes complete this section and, As a nonprofit organization have, Yes, No Go to, If yes date the th week was first, When answering Questions and, Enter the amount of wages you, Jan to March, April to June, July to Sept, and Oct to Dec. Ensure you fill in all needed info to go forward.

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