Ar under Department Workforce Services Form

Ar-tax. org DWS-ARK-201 Rev. 01-07 PAGE 1 OF 2 CONTINUED ON REVERSE SIDE AGRICULTURE EMPLOYMENT SECTION ARE YOU AN AGRICULTURAL EMPLOYER FARM OR RANCH. P. O. Box 8007 Little Rock AR 72203-8007 Telephone 501 682-3798 Department of WORKFORCESERVICES o Individual Sole Proprietor o Political Subdivision 2. FEDERAL EMPLOYER I. D. NUMBER o Professional Association o Trust Report To Determine Liability Under The IDENTIFICATION SECTION 1. ACCOUNT NUMBER ASSIGNED BY DWS IF ANY 3. TYPE OF OWNERSHIP CHECK ONE STATUS REPORT o Corporation 5. o Limited Partnership 10. o Leasing PEO 1a* o LLC o Estate o Partnership o State Agency IF THE TYPE OF BUSINESS IS A CORPORATION/LLC ENTER THE CORPORATE NAME IN ITEM 4 BELOW* 4. NAME 5. MAILING ADDRESS CITY STATE ZIP CODE PHONE NUMBER 6. ENTER THE NAME OR FIRM NAME AND BUSINESS ADDRESS WHERE PAYROLL RECORDS ARE KEPT IF DIFFERENT FROM ITEM 5. NAME If the type of ownership is an individual or partnership enter the name s and social security number s as applicable below or if the type of ownership is a corporation/LLC complete the information for two officers. Do not list Board Members or Directors. 7. Owners Or Corporate Officers Attach Additional Sheet If Necessary 8. Business PHYSICAL LOCATION In Arkansas REQUIRED SOCIAL SECURITY NUMBER TRADE NAME TITLE RESIDENCE ADDRESS CITY STATE ZIP STREET ADDRESS CITY ZIP COUNTY TELEPHONE NO. No* of Employees ORIGINAL CORPORATE NAME IF DIFFERENT THAN ABOVE IF YOUR BUSINESS IS A CORPORATION/ LLC ENTER ADDRESS WHAT PORTION OF THIS ACCOUNT WAS ACQUIRED CHECK ONE ALL* YEAR PART SPECIFY PERCENTAGE ENTER THE DATE YOU BECAME LIABLE FOR STATE UNEMPLOYMENT HAD ONE OR MORE EMPLOYEES IN SOME PART OF TEN DAYS ACA 11-10-209 1. SEE INSTRUCTIONS MONTH DAY SOMEONE IN ARKANSAS* IF YOUR ACCOUNT HAS BEEN INACTIVE NAME OF PREVIOUS OWNER DATE OF ACQUISITION EMPLOYMENT SECTION 11a* PREVIOUS OWNER S ACCOUNT NUMBER IF KNOWN IF THE BUSINESS IN ARKANSAS WAS ACQUIRED FROM ANOTHER LEGAL ENTITY ENTER IF YOU ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE OF 1954 SECTION 501 C 3 ATTACH A COPY OF YOUR EXEMPTION LETTER* INDICATE YOUR PREFERENCE o REIMBURSE o CONTRIBUTORY DOMESTIC - HOUSEHOLD EMPLOYMENT SECTION Complete 14 only if you have domestic or household employees Includes maids cooks chauffeurs sitters etc* 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 REPORTING SECTION DWS ENCOURAGES ALL EMPLOYERS TO REGISTER AND FILE ONLINE AT www. o YES o NO 20 000. 00 OR MORE WERE PAID FOR AGRICULTURAL LABOR VOLUNTARY ELECTION SECTION IF YOU ARE NOT LIABLE UNDER A COMPULSORY PROVISION OF THE DEPARTMENT OF WORKFORCE SERVICES LAW AND WISH TO VOLUNTARILY ELECT COVERAGE FOR YOUR EMPLOYEES CHECK HERE o AND ENTER THE YEAR YOU WISH LIABILITY TO BEGIN AT THE END OF TWO 2 YEARS FROM THIS DATE OR AT THE END OF ANY SUBSEQUENT CALENDAR YEAR YOU MAY WITHDRAW THIS ELECTION BY FILING A WRITTEN REQUEST. YOU WILL BE NOTIFIED OF THIS DETERMINATION IN WRITING* NATURE OF BUSINESS SECTION DESCRIBE FULLY THE NATURE OF YOUR BUSINESS IN ARKANSAS AND LIST THE PRINCIPAL PRODUCTS IN ORDER OF IMPORTANCE CODE SHORT TITLE 11 Agricultural Forestry and Hunting 111 - Crops Production 112 - Animal Production 113 - Forestry and Logging 114 - Fish Hunting and Trapping 115 - Support Services for Agriculture and Forestry 21 Mining 211 - Oil and Gas Extraction 212 - Mining except Oil and Gas 22 Utilities 23 Construction 237 - Heavy and Civil Engineering Construction 238 - Specialty Trade Contractors 31-33 Manufacturing 311 - Food Manufacturing 312 - Beverage and Tobacco Product Manufacturing 313 - Textile Mills 314 - Textile Product Mills 315 - Apparel Manufacturing 316 - Leather and Allied Product Manufacturing 321 - Wood Product Manufacturing 322 - Paper Manufacturing 323 - Printing and Related Support Activities 324 - Petroleum and Coal Products Manufacturing 325 - Chemical Manufacturing 326 - Plastics and Rubber Products Manufacturing 327 - Nonmetallic Mineral Product Manufacturing 331 - Primary Metal Manufacturing 332 - Fabricated Metal Product Manufacturing 333 - Machinery Manufacturing 334 - Computer and Electronic Product Manufacturing 335 - Electrical Equipment Appliance and Component Manufacturing 336 - Transportation Equipment Manufacturing 337 - Furniture and Related Product Manufacturing 339 - Miscellaneous Manufacturing 42 Wholesale Trade 423 - Merchant Wholesalers Durable Goods 425 - Wholesale Electronic Markets and Agents and Broker 44-45 Retail Trade AGENCY USE ONLY NAICS CODE 441 - Motor Vechicle and Parts Dealers 442 - Furniture and Home Furnishings Stores 443 - Electronic and Appliance Stores 444 - Building Material and Garden Equipment and Supplies Dealers 445 - Food and Beverage Stores 446 - Health and Personal Care Stores 447 - Gasoline Stations 448 - Clothing and Clothing Accessories Stores 451 - Sporting Goods Hobby Book and Music Stores 452 - General Merchandise Stores 454 - Nonstore Retailers 48-49 Transportation and Warehousing 481 - Air Transportation 482 - Rail Transportation 483 - Water Transportation 484 - Truck Transportation 485 - Transit and Ground Passenger Transportation 486 - Pipeline Transportation 487 - Scenic and Sightseeing Transportation 488 - Support Activities for Transportation 491 - Postal Service 492 - Couriers and Messengers 493 - Warehousing and Storage 51 Information 511 - Publishing Industries except internet 512 - Motion Picture and Sound Recording Industries 515 - Broadcasting except internet 516 - Internet Publishing and Broadcasting 517 - Telecommunications 518 - Internet Service Providers Web Search Portals and Data Processing Services 519 - Other Information Services 52 Finance and Insurance 521 - Monetary Authorities - Central Bank 522 - Credit Intermediation and Related Activities 523 - Securities Commodity Contracts and Other Financial Investments and Related Activities 524 - Insurance Carriers and Related Activities 525 - Funds Trusts and Other Financial Vehicles 53 Real Estate and Rental and Leasing 532 - Rental and Leasing Services BLS OWN CODE AUX CODE COUNTY CODES BLS 533 - Lessors of Nonfinancial Intangible Assets except Copyrighted Works 54 Professional Scientific and Technical Services 55 Management of Companies and Enterprises 56 Administrative and Support and Waste Management and Remediation Services 562 - Waste Management and Remediation Services 61 Educational Services 62 Health Care and Social Assistance 621 - Ambulatory Health Care Services 622 - Hospitals 623 - Nursing and Residential Care Facilities 624 - Social Assistance 71 Arts Entertainment and Recreation 711 - Performing Arts Spectator Sports and Related Industries 712 - Museums Historical Sites and Similar Institutions 713 - Amusement Gambling and Recreational Industries 72 Accommodation and Food Services 722 - Food Services and Drinking Places 81 Other Services except Public Administration 811 - Repair and Maintenance 812 - Personal and Laundry Services 813 - Religious Grantmaking Civic Professional and Similar Organizations 814 - Private Household 92 Public Administration 921 - Executive Legislative and Other General Government Support 922 - Justice Public Order and Safety Activities 923 - Administration of Human Resource Programs and Community Development 927 - Space Research and Technology 928 - National Security and International Affairs SEASON CODE Type Reimbursable Origination Code 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* AUTHORIZED SIGNATURES OWNER OFFICER PARTNER OR AUTHORIZED AGENT PER POWER OF ATTORNEY.