Enter the Federal Employer Identification Number (FEIN) assigned by the Internal Revenue Service for reporting Social Security, withholding tax, and Federal Unemployment Tax (FUTA). If you have applied for but not received this number, leave this field blank.
Enter the North Carolina Department of Revenue number assigned for withholding tax purposes. If you have applied for but not received this number, leave this field blank.
Enter any previously assigned North Carolina unemployment insurance tax number.
Enter the legal name of the individual(s) (use first, middle, and last name with no initials) or Corporation for which this report is submitted as follows:
For a proprietorship, name of owner;
For a two-way general partnership, name of both partners;
For a general partnership of more than two partners, one general partner followed by "et al.";
For a limited partnership, one general partner followed by "et al.";
For a corporation, the corporate name as registered with the Office of the Secretary of State of North Carolina
Do not input address information here.
Enter the trade name of the business. If no trade name is used, leave this item blank.
Do not input address information here.
Enter the complete U.S. postal mailing address for business correspondence - include the zip +4 code. Answer "Yes" if this is an international address.
Enter the area code and telephone number for the business.
Enter the area code and fax number for the business.
Enter the name, title, telephone number, and e-mail address, if applicable, of the person to contact for questions concerning unemployment tax matters.
Enter the address of the physical location (no post office box) of the North Carolina business. Fax a list of ALL operating business names and locations in North Carolina to 919-715-0780, or mail to . If there is no base of operations in North Carolina, enter the home address of the primary North Carolina employee.
Indicate the appropriate type of ownership. If "Other", enter the type of organization, such as Estate, Association, or Church.
Describe the type of services performed, products made, sold, etc.
If the business for which this form is being completed is part of a larger organization and primarily provides support services to that organization rather than to the public or other businesses, indicate the appropriate activity. If "Other", please describe the activity. If there are any questions concerning this item, contact the Labor & Economic Analysis Division at .
Enter the date one or more workers were first employed in North Carolina.
Items 15 through 20 - Enter the requested information for the ONE item that applies to North Carolina employment.
Most employment is considered general business employment. This includes all types of work except domestic services, such as maids, gardeners, agricultural service, and service performed for governmental or 501(c)(3) nonprofit organizations.
Consider all payments made to individuals who performed services in general business employment. For corporations, include amounts paid to all active and/or paid officers of the corporation.
In determining employment for each calendar week (Sunday through Saturday), use the greatest number of workers (full-time or part-time) on any day of the week. All employees do not need to work each day or during the same hours each day. For corporations, include all active and/or paid officers of the corporation in the count.
An employee leasing company is an employee service or temporary help service that, under contract, supplies individuals to perform services for clients or customers. (NOTE: Not a consulting company)
Consider only monetary payments to all individuals who performed services in agricultural labor.
Count any week in which as many as 10 individuals were employed in agricultural labor on any day.
Domestic employment includes all service for a person in the operation and maintenance of a private household, local college club or local chapter of a college fraternity or sorority. Domestic employees include such workers as chauffeurs, cooks, babysitters, gardeners, maids, butlers, and home nurses. Include only monetary payments made to individuals who performed domestic service.
Answer this question only if this business is a non-profit organization exempt from federal income tax under Section 501(c)(3) of the Internal Revenue Code. Fax a copy of the IRS letter that grants this exemption to 919-715-0780. Note "Web604" on the facsimile cover sheet. Non-profit organizations with tax exemptions other than Section 501(c)(3) should complete item 15, GENERAL BUSINESS EMPLOYMENT.
Indicate if this business is an agency or department of federal, state, or local government.
Answer "Yes" to voluntarily cover employees for unemployment insurance, when the business is not otherwise subject to the unemployment insurance tax law.
Answer "Yes" if the business has paid, or is required to pay Federal Unemployment Tax (FUTA). Enter the calendar year(s) for which FUTA is/was required.
Answer "Yes" if the business has acquired or merged with another business, or any other changes have been made in the ownership of the business. This includes entity changes, such as from a sole proprietorship to a corporation or a partnership.
Enter the name of the former owner.
Enter the former owner's North Carolina unemployment insurance tax number.
Enter the former owner's address.
Enter the date of the acquisition or change.
Indicate whether you acquired substantially all or a portion of the former owner's North Carolina business.
Indicate if the business was operating at the time that it was acquired. If applicable, enter the date the business closed.
Indicate if the former owner continues to have employees in North Carolina.
Be sure to provide all the requested information about the previous owner.
If "Yes", fax a list of independent contractor(s) who do not have a Federal Employer Identification Number. Include name(s), address(es), telephone number(s), and Social Security number(s). The Fax Number is 919-715-0780.
Provide for ALL parent corporations, sole proprietors, all general partners, principal corporate officers, or members full name(s), title(s), Social Security number(s), home address(es) (do not use a post office box), and telephone number(s) including the area code. If additional space is needed, fax a list. Do not provide information for limited partners.
Be sure all applicable items are completed.
Please mail or fax 501(c)(3) exemption letters, independent contractor lists, lists of additional owners/officers, and/or additional lists to:
North Carolina Department of Commerce
Division of Employment Security
Please call 919-707-1150 if you have any questions.