LIA2699X (2) ID FOR Employer No. AGENCY ED SD DD USE A. & I. Sec. ONLY Special Indicators 1 2 3 4 5 6 NAICS CODE You are required to complete this form even if you have never had any employees.
Complete and return within 10 days to Division of Employment Security, P O Box 59, Jefferson City, Missouri 65104-0059. 1. Employing Unit/Employer Name & Address 2. Account # 3. Business Phone # 3a) Fax Phone # 4. Owner Home Phone # 5. Federal Identification #
6. If mailing address differs from Item 1, enter here: 6a) Give phone number and address where you maintain payroll/disbursement records:
7. Check type of business organization: Individual Estate Association Partnership Corporation Other Limited Partnership *LLC If corporation, limited partnership, LLC, or LLP show state where registered: Charter Number: Date Issued: *If LLC is indicated, check how the business is taxed Individual Partnership Corporation 8. Trade name/Business name if other than what appears in Item 1: 9. List owner, partners or officers (attach list if necessary). Name Social Security No. Residence Address Title
10. First date on which you had one (1) or more workers in Missouri: 10a) Description of business activities and locations in Missouri. List each location separately or attach list. Avg. No. Business Location Address County Nature of Business/Activities of Workers 10b) If no MISSOURI locations, check here 10c) Show DATE in appropriate blank: New business (no prior owner/operator) Partial Acquisition Merger Acquired a business Incorporated an existing business Stock ownership change Other (explain) 10d) Name, address and telephone number of previous operator: 10e) Did you continue without interruption all of the previous operators business activities in Missouri? Yes No
If only a part of the business was acquired, explain what was acquired and the percentage of the business operations acquired: If activities were interrupted between operators, explain why: (CONTINUE ON NEXT PAGE)11. Do you provide leased employees to anyone? Yes No 11a) Are you leasing employees from anyone? Yes No 11b) Is there common ownership, management or control with the previous operator? Yes No If Yes, please explain: 12. Were you liable under the Federal Unemployment Tax Act in ANY STATE in
(answer Yes or No for each year) 2006 2007 2008 2009 NOTE: If you are operating as a sole proprietor, DO NOT include yourself, your spouse, mother, father or natural, adopted, foster or stepchildren under the age of 21 when completing Items 10, 13 and 14.
13. List Missouri
wages paid in
each calendar
quarter by type
of employment.
Include paid
officers.
Do Not
Estimate
Wages Year Type of Employment 1st Quarter Wages 2nd Quarter Wages 3rd Quarter Wages 4th Quarter Wages
Business 2007 Agricultural Domestic Business 2008 Agricultural Domestic Business 2009 Agricultural Domestic Business 2010 Agricultural Domestic 13a) If you are showing no wages paid, give date you anticipate hiring workers: 13b) If you do not expect to have workers in Missouri, explain: 14. Check each week in which someone worked. Include corporate officers, full and part-time workers, commission salespersons, etc.
Agricultural and non-profit 501(C)(3) employers must enter actual number of workers in each week. Week-Ending JAN
6 JAN
13 JAN
20 JAN
27 FEB
3 FEB
10 FEB
17 FEB
24 MAR
3 MAR
10 MAR
17 MAR
24 MAR
31 APR
7 APR
14 APR
21 APR
28 MAY
5 MAY
12 MAY
19 MAY
26 JUN
2 JUN
9 JUN
16 JUN
23 JUN
30 Dates 2007 JUL
7 JUL
14 JUL
21 JUL
28 AUG
4 AUG
11 AUG
18 AUG
25 SEP
1 SEP
8 SEP
15 SEP
22 SEP
29 OCT
6 OCT
13 OCT
20 OCT
27 NOV
3 NOV
10 NOV
17 NOV
24 DEC
1 DEC
8 DEC
15 DEC
22 DEC
29 DEC
31 Week-Ending JAN
5 JAN
12 JAN
19 JAN
26 FEB
2 FEB
9 FEB
16 FEB
23 MAR
1 MAR
8 MAR
15 MAR
22 MAR
29 APR
5 APR
12 APR
19 APR
26 MAY
3 MAY
10 MAY
17 MAY
24 MAY
31 JUN
7 JUN
14 JUN
21 JUN
28 Dates 2008 JUL
5 JUL
12 JUL
19 JUL
26 AUG
2 AUG
9 AUG
16 AUG
23 AUG
30 SEP
6 SEP
13 SEP
20 SEP
27 OCT
4 OCT
11 OCT
18 OCT
25 NOV
1 NOV
8 NOV
15 NOV
22 NOV
29 DEC
6 DEC
13 DEC
20 DEC
27 DEC
31 Week-Ending JAN
3 JAN
10 JAN
17 JAN
24 JAN
31 FEB
7 FEB
14 FEB
21 FEB
28 MAR
7 MAR
14 MAR
21 MAR
28 APR
4 APR
11 APR
18 APR
25 MAY
2 MAY
9 MAY
16 MAY
23 MAY
30 JUN
6 JUN
13 JUN
20 JUN
27 Dates 2009 JUL
4 JUL
11 JUL
18 JUL
25 AUG
1 AUG
8 AUG
15 AUG
22 AUG
29 SEP
5 SEP
12 SEP
19 SEP
26 OCT
3 OCT
10 OCT
17 OCT
24 OCT
31 NOV
7 NOV
14 NOV
21 NOV
28 DEC
5 DEC
12 DEC
19 DEC
26 DEC
31 Week-Ending JAN
2 JAN
9 JAN
16 JAN
23 JAN
30 FEB
6 FEB
13 FEB
20 FEB
27 MAR
6 MAR
13 MAR
20 MAR
27 APR
3 APR
10 APR
17 APR
24 MAY
1 MAY
8 MAY
15 MAY
22 MAY
29 JUN
5 JUN
12 JUN
19 JUN
26 Dates 2010 JUL
3 JUL
10 JUL
17 JUL
24 JUL
31 AUG
7 AUG
14 AUG
21 AUG
28 SEP
4 SEP
11 SEP
18 SEP
25 OCT
2 OCT
9 OCT
16 OCT
23 OCT
30 NOV
6 NOV
13 NOV
20 NOV
27 DEC
4 DEC
11 DEC
18 DEC
25 DEC
31 15. Are you an organization exempted from Federal income taxes under Section 501(c)(3) of the Internal Revenue Code? Yes No.
If Yes, furnish proof. Information regarding your status, rights, and responsibilities under the Missouri Employment Security Law will be furnished. This information is required to be provided pursuant to Chapter 288 RSMo and 8 CSR 10-4.020 of the Missouri Division of Employment Security and the Internal Revenue Code (26 U.S.C. 85; 6011(a) 6050 B, and 6109(a)), and will only be used by public officials in the performance of their public duties. SIGN HERE Title Date Telephone Number Under authority of Section 6103(d) of the Internal Revenue Code, the Internal Revenue Service provides this agency with information necessary for Certification and Audit purposes.
MODES-2699-5 (11-09) AI
Cont.
MODES-2699-5-2 (11-09) AI
STATE OF MISSOURI
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF EMPLOYMENT SECURITY
573-751-3340
FAX 573-751-7483
REPORT TO DETERMINE LIABILITY STATUS
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