Mail To:                                                                                                                  Register Online at www.texasworkforce.org 
Cashier - Texas Workforce Commission 
P.O. Box 149037 - Austin, TX 78714-9037 
512.463.2731 
                                                                      STATUS REPORT 
                                                     THIS REPORT IS REQUIRED OF EVERY EMPLOYING UNIT, 
                   AND WILL BE USED TO DETERMINE LIABILITY UNDER THE TEXAS UNEMPLOYMENT COMPENSATION ACT. 
                  HOWEVER, IF YOU HAVE EMPLOYMENT IN TEXAS ON A FARM OR RANCH, DO NOT COMPLETE THIS FORM.  PLEASE COMPLETE  
                  FORM C-1FR, AVAILABLE ON OUR WEBSITE, TO DETERMINE IF YOU ARE LIABLE FOR YOUR FARM OR RANCH EMPLOYEES. 
                                                                                                                   
                                                             IDENTIFICATION SECTION 
1. ACCOUNT NUMBER ASSIGNED BY TWC (IF ANY)  2. FEDERAL EMPLOYER ID NUMBER                3.  TYPE OF OWNERSHIP (CHECK ONE) 
                                                                                          
4.         NAME                                                                                 CORPORATION/PA/PC                       LIMITED PARTNERSHIP 
                                                                                                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.                                                          ADDRESS                                                                   PHONE NUMBER 
 BUSINESS ADDRESS WHERE RECORDS OR                                                                                                     (      )           
                  PAYROLLS ARE KEPT:                         CITY                                                 STATE                ZIP  
                  (IF DIFFERENT FROM ABOVE)                                                                                                       
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 CORPORATION, ENTER: 
FILING NUMBER                STATE INCORPORATED              DATE INCORPORATED         REGISTERED AGENT'S NAME 
                                                                                                  
REGISTERED AGENT'S ADDRESS                              ORIGINAL CORPORATE NAME, IF NAME HAS CHANGED 
                                                                       
                                                                      EMPLOYMENT SECTION 
14.                                                                                                                                         MONTH        DAY           YEAR 
                           ENTER THE DATE YOU FIRST HAD EMPLOYMENT IN TEXAS (DO NOT USE FUTURE DATE):                                                                       
15.                                                                                                                                                                     
                  ENTER THE DATE YOU FIRST PAID WAGES TO AN EMPLOYEE IN TEXAS (DO NOT USE FUTURE DATE): 
                                                                                                                                                                            
16.                                                                                                                                                                     
 
IF YOUR ACCOUNT                                         ENTER THE DATE YOU RESUMED EMPLOYMENT  IN TEXAS:                                                                    
      HAS BEEN                                                                                                                                                          
      INACTIVE:                                        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 ENDING DATE (SATURDAY) OF THE TWENTIETH WEEK IN THE CALENDAR YEAR THAT 
INDIVIDUALS WERE EMPLOYED IN TEXAS. (INCLUDE ANY WEEK IN WHICH ANYONE PERFORMED SERVICE                                                                                     
FOR ANY PORTION OF ANY DAY DURING THAT WEEK.  THIS INCLUDES FULL-TIME, PART-TIME, PERMANENT 
AND TEMPORARY EMPLOYEES.  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 DATE) 
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                                                                                       
TWENTIETH  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  

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                                               DOMESTIC - HOUSEHOLD EMPLOYMENT SECTION 
                                   COMPLETE 22 ONLY IFYOU            HAVE DOMESTIC OR HOUSEHOLD EMPLOYEES                     
                                               (INCLUDES MAIDS, COOKS, CHAUFFEURS, GARDENERS, ETC.) 
 22.                                                                                                                          MONTH           DAY   YEAR 
 ENTER THE ENDING DATE OF THE FIRST CALENDAR QUARTER IN WHICH YOU PAID GROSS WAGES OF $1,000                                                                 
                                   OR MORE TO EMPLOYEES PERFORMING DOMESTIC SERVICE: 
                                                                                                       
                                                         NATURE OF ACTIVITY SECTION 
 23. 
  DESCRIBE FULLY THE NATURE                            
     OF ACTIVITY IN TEXAS, AND                         
 LIST THE PRINCIPAL PRODUCTS                           
      OR SERVICES IN ORDER OF 
             IMPORTANCE:                               
 24                                         PREVIOUS OWNER’S TWC ACCOUNT NUMBER (IF KNOWN)                       DATE OF ACQUISITION 
 IF THE BUSINESS IN TEXAS WAS                                                                                     
     ACQUIRED FROM ANOTHER                                                                                                  
      LEGAL ENTITY, YOU MUST                NAME OF PREVIOUS OWNER(S) 
      COMPLETE ITEMS 24-27.                  
                                                       
 ADDRESS                                                                         CITY                             STATE      ZIP 
                                                                                                                                        
 WHAT PORTION OF BUSINESS WAS ACQUIRED?  (CHECK ONE) 
      ALL 
      PART (SPECIFY           )                                                                                                                                 
 25.                                                                                                                           
 ON THE DATE OF THE ACQUISITION, WAS THE PREVIOUS OWNER(S), OR ANY PARTNER(S), OFFICER(S),                                     
 SHAREHOLDER(S), OTHER OWNER(S) OR A PERSON RELATED BY BLOOD OR MARRIAGE TO ANY OF THESE                                       
 INDIVIDUALS, HOLDING A LEGAL OR EQUITABLE INTEREST IN THE PREDECESSOR BUSINESS, ALSO AN                                                      YES   NO  
 OWNER, PARTNER, OFFICER, SHAREHOLDER, OR OTHER OWNER OF A LEGAL OR EQUITABLE INTEREST IN 
 THE SUCCESSOR BUSINESS?  
 IF “YES”, CHECK ALL THAT APPLY: 
            SAME OWNER, OFFICER, PARTNER, OR SHAREHOLDER                                             SOLE PROPRIETOR INCORPORATING 
            SAME PARENT COMPANY                                                                      OTHER  (DESCRIBE BELOW) 
                                                                                                                                                              
 26.                                                                                                                           
 IF “NO,” ON THE DATE OF THE ACQUISITION, DID THE PREVIOUS OWNER(S), PARTNER(S), OFFICER(S), 
 SHAREHOLDER(S), OTHER OWNER(S) OR A PERSON RELATED BY BLOOD OR MARRIAGE TO ANY OF THESE                                       
 INDIVIDUALS, HOLDING A LEGAL OR EQUITABLE INTEREST IN THE PREDECESSOR BUSINESS, HOLD AN                                                      YES            NO  
 OPTION TO PURCHASE SUCH AN INTEREST IN THE SUCCESSOR BUSINESS? 
 27.                                                                                                                           
 AFTER THE ACQUISITION, DID THE PREDECESSOR CONTINUE TO: 
 •    OWN OR MANAGE THE ORGANIZATION THAT CONDUCTS THE ORGANIZATION, TRADE OR BUSINESS?                                            YES                NONO  
 •    OWN OR MANAGE THE ASSETS NECESSARY TO CONDUCT THE ORGANIZATION, TRADE OR BUSINESS?                                           YES              NO 
 •    CONTROL THROUGH SECURITY OR LEASE ARRANGEMENT THE ASSETS NECESSARY TO CONDUCT THE                                        
      ORGANIZATION, TRADE OR BUSINESS?                                                                                             YES              NO 
 •    DIRECT THE INTERNAL AFFAIRS OR CONDUCT OF THE ORGANIZATION, TRADE OR BUSINESS?                                               YES              NO 
 IF “YES” TO ANY OF ABOVE, DESCRIBE:   
                                                                                                                                                               
                                                         VOLUNTARY ELECTION SECTION 
 28. 
 A NON-LIABLE EMPLOYER MAY ELECT TO PAY STATE UNEMPLOYMENT TAX VOLUNTARILY.  IF AN EMPLOYER ELECTS TO DO SO, THE 
 EMPLOYER IS OBLIGED TO PAY TAXES FOR A MINIMUM OF TWO CALENDAR YEARS, BEGINNING WITH JANUARY 1 OF THE FIRST YEAR OF 
 THE ELECTION.  THE EMPLOYER MAY WITHDRAW THE ELECTION BY WRITTEN REQUEST, AT THE END OF THE 2-YEAR PERIOD, IF NOT YET 
 LIABLE UNDER THE TEXAS UNEMPLOYMENT COMPENSATION ACT.  TO ELECT THIS OPTION, COMPLETE THE FOLLOWING: 
    YES      EFFECTIVE JAN. 1,          I WISH TO COVER ALL EMPLOYEES (EXCEPT THOSE PERFORMING SERVICE(S) WHICH ARE 
      NO     SPECIFICALLY EXEMPT IN THE TEXAS UNEMPLOYMENT COMPENSATION ACT). 
                                                                                                       
                                                                SIGNATURE SECTION 
 I HEREBY CERTIFY THAT THE PRECEDING INFORMATION IS TRUE AND CORRECT, AND THAT I AM AUTHORIZED TO EXECUTE THIS STATUS 
 REPORT ON BEHALF OF THE EMPLOYING UNIT NAMED HEREIN. (THIS REPORT MUST BE SIGNED BY THE OWNER, OFFICER, PARTNER OR 
 INDIVIDUAL WITH A VALID WRITTEN AUTHORIZATION ON FILE WITH THE TEXAS WORKFORCE COMMISSION) 

  DATE OF                    MONTH      DAY         YEAR   SIGN HERE                                                                 TITLE   
 SIGNATURE: 
 DRIVER'S LICENSE NUMBER                       STATE       E-MAIL ADDRESS 
                                                                     
Individuals may receive, reviewth  and correct information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to TWC 
Open Records, 101 E. 15  St., Rm. 266, Austin, TX  78778-0001. 

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