Ui 1 Form – Fill Out and Use This PDF

MDES OFFICIAL INFORMATION

Found Date (MM/DD/CCYY):

DO NOT WRITE ABOVE THIS LINE.

EMPLOYER ENTITY INFORMATION

1.

Federal Employer ID Number (FEIN):

-

2.

Organization Type:

Corporation

Partnership

Individual

Non-Profit Corp.

Corporate LLC

Partnership LLC

Individual LLC

Other (enter type):

3.

IF A CORPORATION: a. State of Incorporation:

b. Date of Incorporation (MM/DD/CCYY):

c. State of Legal Domicile:

4. IF INDIVIDUAL OWNER:

Do you employ any individual(s) not including yourself, your spouse or your children under 21 years of age?

YES

NO

5.

Legal Entity Name:

6. Business Name (D/B/A):

7.

Have you paid employees for work performed in Mississippi?

YES

NO

7. a. If Yes, provide the date (MM/DD/CCYY) you first

employed someone in Mississippi:

8.

Does this business consist solely of agricultural work?

YES

NO

9.

Does this business employ domestic help?

YES

NO

(This includes housekeepers, sitters, or other domestic employment)

10.

Are you applying for reimbursable status under the Indian Tribal Law?

YES

NO

11.

Is this organization a State College, State University or State Hospital?

YES

NO

12.

Is this business FUTA (Federal Unemployment Tax) liable in another state? YES

NO

13.

Are you a Professional Baseball Concessionaire?

YES

NO

14.

Do you have a Third Party that handles your payoll and/or tax matters?

YES

NO

a. If Yes, Third Party authorized to handle matters for Unemployment Tax:

b. Agent/Officer Phone:

Name:

(

)

-

ext.

Title:

15.

Do you have business location(s) in Mississippi?

YES

NO

a. If Yes, list below your places of business in Mississippi and give a description of your operations at each place of business.

City

County

Number of Employees

Principal Business Activity

16.

Are you exempt as an IRS 501 (C) (3) Non-Profit Organization?

YES

NO

a. If Yes, attach a copy of your 501(C) (3) exemption.

EMPLOYER CONTACT DETAILS

1. Physical Address

Address:

City:

State:

Country:

ZIP Code:

Phone:

(

)

-

2. Unemployment Tax Mailing Address

Same as previous

Attention:

Address:

City:

State:

Country:

ZIP Code:

Phone: (

)

-

Contact Name (First, MI, Last):

Phone:

(

)

-

ext.

3. Unemployment Claims Mailing Address

Same as previous

Address:

City:

State:

Country:

ZIP Code:

Phone:

(

)

-

FAX: (

)

-

Mississippi Department of Employment Security is an equal opportunity employer.

UI-1 R-12/2006

Web Address: www.mdes.ms.gov

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

Page 1 of 3

4.

Payroll Mailing Address

Same as previous

Address:

City:

State:

Country:

ZIP Code:

Phone: (

)

-

FAX: (

)

-

5.

Officer or Resident Agent authorized to furnish payroll information:

Name:

Title:

6.

Preferred Mode of Correspondence:

USPS

E-Mail

Telephone

FAX

Other (enter type):

7.

Employer E-Mail Address:

BUSINESS OWNERSHIP

1.

List the Name, Title, Social Security Number and Address of the Proprietor, Partners or Corporate Officers.

NAME (First, MI, Last)

TITLE

SSN

ADDRESS

-

-

-

-

-

-

2.

Beginning Date of Employment in Mississippi (MM/DD/CCYY):

3. Date Acquired (MM/DD/CCYY):

4.

Did you acquire (purchase, inherit, etc) this business?

Yes

No

If yes, provide details about the previous owner below.

a. Name this business was operating under (Doing Business As):

b. Federal Employer Identification Number (FEIN)

-

c. Previous Owner’s Current Address:

d. MDES Employer Account Number (EAN):

-

-

-

e. Phone:

(

)

-

ext.

f. Does this BUSINESS continue to operate?

Yes

No

5.

Have you ever been registered with the Mississippi Department of Employment Security?

Yes

No

a. If Yes, provide previous MDES Employer Account Number (EAN):

-

-

-

b. If Yes, provide previous Federal Employer Identification Number (FEIN):

-

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Mississippi Department of Employment Security is an equal opportunity employer.

UI-1 R-12/2006

Web Address: www.mdes.ms.gov

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

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Mississippi Department of Employment Security is an equal opportunity employer.

UI-1 R-12/2006

Web Address: www.mdes.ms.gov

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

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