Texas Workforce Commission Report – Fill Out and Use This PDF

1. Account Number assigned by TWC (if any)

2. Federal Employer ID Number

3. Type of ownership (check one)

corporation/pa/pc

limited partnership

4. Name

partnership

estate

individual (sole proprietor/domestic)

trust

5. Mailing address

limited liability company

other (specify)

6. City

7. County

8. State

8(a). Zip code

9. Phone Number

(

)

10.

Business address where records or payrolls are kept:

(if different from above)

Address

City

State

Zip

Phone Number ( )

11.

Owner(s) or officer(s) [attach additional sheet if necessary]

Name

Social Security No.

Title

Residence Address, City, State, Zip

12.

Business locations in Texas [attach additional

sheet if necessary]

Trade name

Street Address, City, Zip

Kind of business

No. of employees

13.

If your business is a chartered legal

entity, enter:

Charter number

State of Charter

Date of Charter

Registered agent's name

Registered agent's address

Original legal entity name, if name has changed

14.

Enter the date you first had employment in Texas (do not use future date):

Month

Day

Year

15.

Enter the date you first paid wages to an employee in Texas (do not use future date):

16.

If your account has been inactive:

Enter the date you resumed employment in Texas:

Enter the date you resumed paying wages in Texas:

17.

Enter the ending date of the first quarter you paid gross wages of $1,500.00 or more:

18.

Enter the Saturday date of the 20th week that individuals were employed in Texas.

(All weeks should be in the same calendar year. Count a week if anyone performed any service for any portion of any day.

The services do not have to be performed on the same day of the week, in consecutive weeks or by the same employee. If

you do not reach 20 weeks of employment in the first calendar year of operation, begin again with the second calendar year

and count until you reach 20 weeks in that year.) Do not use future dates

19.

If you hold an exemption from Federal Income Taxes under Internal Revenue Code Section 501(c)(3), attach a copy of your

Exemption Letter. Also, enter the ending date of the 20th week of the calendar year in which 4 or more persons were

employed in Texas:

20.

Enter the year(s) your organization was liable for taxes under the Federal Unemployment Tax Act:

(begin with most recent year)

(year)

(year)

(year)

(year)

21. Does this employer employ any U.S. citizens outside of the U.S.?

Yes

No

C-1 (091415)

Page 1 of 2

22. Enter the ending date of the first calendar quarter in which you paid gross wages of $1,000 or more to employees

Month

Day

Year

performing domestic service:

Nature of Activity Section

a)

Previous owner’s TWC Account Number (if known)

______________________________________________________________________________

b)

Date of acquisition

_________________________________________________________________________________________________________

c)

Name of previous owner(s)

_________________________________________________________________________________________________

d)

Address

________________________________________________________________________________________________________________

equitable interest in the successor business?

Yes

No

If “Yes” to any of above, describe:

_____________________________________________________________________________________________

Yes, effective Jan. 1,

I wish to cover all employees (except those performing service(s) which are specifically exempt in the Texas Unemployment

Compensation Act).

Signature Section

Month ___ Day

___ Year ___

Sign here ________________________________________

Title

_______________

Driver's license number

__________________ State

__________ E-mail address

______________________________________________

C-1BK (091415)

Page 2 of 2