(Do not write in this space)           Account #
                                                                                                   Subject
                                                                                                   Retroactive
                                                                                                   Successor
                           45 South Fruit Street                                                   Acquisition
    Concord, New Hampshire 03301-4857
                                                                                                   Not Subject
Phone (603) 228-4142   Fax (603) 225-4323
                           www.nhes.nh.gov                                                         NAICS

                                                  EMPLOYER STATUS REPORT
                           PLEASE READ INSTRUCTIONS THEN COMPLETE ALL ITEMS (TYPE OR PRINT LEGIBLY)
To establish its status under the provisions of the New Hampshire Unemployment Compensation Law, each employing unit is 
required by the law to fi le with this department an Employer Status Report (RSA 282-A).
1.                                                                                              2. Federal Identifi cation Number
                                                                                                        -
    BUSINESS NAME OR TRADE NAME
                                                                                                3. For your employment in NH, describe in 
    Address of principal place of business in NH, if none, indicate other state. (Do NOT use PO    detail your principal activity
                      box) If more than one NH location, attach a separate sheet and list all.

    CITY                                          STATE     ZIP CODE                            3a. For your employment in NH, describe in 
                                                                                                   detail your principal products, processes, 
                                                                                                   or services.
    PHONE NUMBER                                  FAX NUMBER

    E-MAIL                                                                                      4. Check (x) type of business
                                                                                                   Sole                                                       LLC 
    MAILING ADDRESS IF DIFFERENT FROM ABOVE                                                        Proprietorship                                             (Single member)

                                                                                                   Partnership                                                LLC (Partnership)
    STREET ADDRESS OR POST OFFICE BOX
                                                                                                   Corporation                                                LLC (Corporation)
    CITY                                          STATE     ZIP CODE
                                                                                                   Other

    PHONE NUMBER                                  FAX NUMBER

5.  If a corporation or LLC, enter the following: Date of Registration         /        /          State of Registration                             
    Full corporate or LLC name:                                                                                                                                              
6.  Is your business a nonprofi t organization described in Section 501(c)(3) and exempt under 501(a) of the Internal Revenue Code?
                    Yes    No   If Yes, attach a copy of your letter of exemption.
7.  Enter date on which employment was fi rst furnished in New Hampshire         /        /        
    Enter date wages were fi rst paid in New Hampshire         /        /        
8.  Ceased to furnish employment in NH on         /        /          Reason:                                                                                  
9.  Are or will you be subject to the Federal Unemployment Tax Act in the current year?
                                                                                                          Yes     No
10. Has employment been furnished in NH in preceding years during which you were subject to the Federal Unemployment Tax Law?
                    No     Yes, list years: 
11. Did you acquire the organization, trade, business, workforce, or any of the New Hampshire assets of any other employing unit 
    or employer?
           Yes             If Yes, date of acquisition:         /        /        , % of assets acquired               , then complete questions 11a thru 11d.
                      No   If No, skip to item 12.
11a. Please provide the name and address of prior owner.

                                                            (OVER)                                                NHES 0037 R-10/15

11b.     Check (x) the type of change:
          Reorganization                                                                         Purchase Assets of business
          Transfer of trade of business                                                          Merger
          Change of entity (e.g. proprietorship to corporation)                                  Lease of business
          Transfer of workforce (employees) If checked, must complete Trade, Business, and Workforce Transfer Report.
11c.     Were there any business assets not acquired?       Yes              No
         If yes, list business assets not acquired:                                                                                                                                                                            
11d.     Will the prior owner remain in business in NH?     Yes              No
         If yes, please explain:                                                                                                                                                                                                           
12.      Enter the gross payroll of your business for the current and two prior calendar years. (New Hampshire Payroll Only)
     Calendar Year            1st Quarter                       2nd Quarter                          3rd Quarter                  4th Quarter
$                         $                             $                                        $
$                         $                             $                                        $
$                         $                             $                                        $
13.      Do you expect to have a gross payroll of at least $1,500 in a calendar quarter?
         Yes       Enter the earliest quarter and year this occurred (or will occur)                                                                                                                     
         No        If No, have you or do you expect to employ at least one worker in 20 different weeks in a calendar year?
         If so, when did this occur (or will occur)?                                                                                                                                                                    
14.  Enter by week the number of workers to whom you furnished employment in New Hampshire. Show current calendar year employment f rst, followed by 
employment in all preceding calendar years. Note: A week is seven consecutive calendar days beginning at 12:01 am Sunday and ending as 12:00 midnight on 
the next succeeding Saturday. (Emp 101.01)
CALENDAR YEAR: __________                 CALENDAR YEAR: __________                                    CALENDAR YEAR: __________
     1st 2nd       3rd    4th 5th                       1st    2nd           3rd 4th             5th              1st         2nd 3rd 4th       5th
JAN                                       JAN                                                              JAN
FEB                                       FEB                                                              FEB
MAR                                       MAR                                                              MAR
APR                                       APR                                                              APR
MAY                                       MAY                                                              MAY
JUN                                       JUN                                                              JUN
JUL                                       JUL                                                              JUL
AUG                                       AUG                                                              AUG
SEP                                       SEP                                                              SEP
OCT                                       OCT                                                              OCT
NOV                                       NOV                                                              NOV
DEC                                       DEC                                                              DEC
15.  In addition to the employment shown under item 14, did you engage in any “self employed individuals”, “sub-contractors”, consultants”, etc?
         No              Yes, furnish name, trade, and address below (use block 19 or a separate sheet if necessary)
                                          Domestic-Household Employment Section
16.  Have you had or do you expect to have a $1,000 quarterly payroll for domestic service?            Yes                  No
     If Yes, give the earliest quarter and year this occurred (or will occur). Quarter ________ Year _________
17.  If this report is prepared by other than a sole proprietor, this item must be completed.
     I (we) declare under penalty of law (RSA 282-A:166) that I (we) prepared this report for the employing unit named herein and that this report, includ-
     ing any accompanying schedules and statements, is to the best of my (our) knowledge and belief, a true, correct, and complete report based on all 
     the information relating to the matters required to be reported in this report of which I (we) have any knowledge.

     NAME                                                      FIRM NAME                                                    DATE

     SIGNATURE                                                  ADDRESS                                                     PHONE
18.  This report must be signed by owner, all partners, authorized corporate off cers, and authorized members of limited liability companies.
     It is hereby certif ed that the information in this report, including any attached sheets, is true and correct to the best of my (our) knowledge and
     belief and is signed under penalty of law (RSA 282-A:166).
    Name (Type or Print)  Social Security Number               Resident Address                        Title                      Signature

19.      Remarks