HTML Preview Employer Status Report Form page number 1.
THIS REPORT IS REQUIRED OF EVERY EMPLOYING UNIT AND WILL BE USED TO DETERMINE LIABILITY UNDER
THE NORTH CAROLINA EMPLOYMENT SECURITY LAW, GENERAL STATUTE 96 AND DIVISION REGULATIONS.
NCUI 604 (Rev 01/2012) OVER PLEASE
Employer Status Report
Please Read Instructions!
NC Dept. of Commerce
Division of Employment Security
Post Office Box 26504
Raleigh, N.C. 27611-6504
Please Type or Print in Black Ink
or File Online www.ncesc.com
Return Within 10 Days
1.
Federal ID number:__________________
2. N.C. Dept. of Revenue withholding ID number:
3.
Enter any previously assigned North Carolina unemployment tax numbers:
4.
Employer name:
Enter exact name of legal entity – for further details see instructions)
5.
Trade name:
6.
Mailing address:
Street or P.O. Box
City
State
Zip Code
7.
Phone number: (_______)_____________________________
8. FAX number: (_______)
9.
Contact person: ________________________________________________
Title
Phone number: ( ______ )________________________ E-mail Address:
10.
N.C. business location:
Street (Do not use a post office box)
Number of Employees expected
in the next 12 months:
N.C.
City
Zip Code
County
(Attach a list of ALL NC locations, if there is no NC business location, enter the primary employee’s home address)
11.
Check type of ownership:
Individual
Sub-Chapter S Corporation
LLC taxed as Individual
General Partnership
Corporation
501(c)(3) - Attach a copy
Governmental
LLC taxed as Partnership
LLC taxed as Corporation
Limited Partnership - Attach a list of ALL General
Partners
Indian Tribal Governments/Enterprises
Disregarded Entity
Other:
12.
Enter the principal activity or services performed in your North Carolina operation:
13.
If you are part of a larger organization and are primarily engaged in providing support services to that organization,
check one of the following:
Control, Administrative (Headquarters, etc.)
Storage/Warehouse
Research, Development or Testing
Other
14.
Enter date you first employed one or more workers in North Carolina: _________/________/___________
MM DD YYYY
For Items 15 through 20, check only the ONE item that applies
15.
GENERAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $1,500 or more? Yes No
_____/_______/_______
If yes, enter the date this occurred or will occur. MM DD YYYY
b. Have you or will you employ at least one worker in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No _____/_______/______
_____/_______/_______
MM DD YYYY
16.
Are you an EMPLOYEE LEASING company? Yes No
17.
AGRICULTURAL EMPLOYERS:
a. Have you or will you have a quarterly payroll of $20,000 or more?
If yes, enter the date this occurred or will occur Yes No _____/_______/_______
MM DD YYYY
b. Have you or will you employ at least 10 workers in 20 different calendar weeks during a
calendar year?
If yes, enter the date this first occurred or will occur. Yes No _____/_______/_______
MM DD YYYY
For Agency Use Only:
Account No.
Liable
Y N
A/C/AS
Root
OW/OF
S Add
ET AL
S/PR
BR
Liab Date
Del After
Law Sec
M/W
County
ERA
Own
Curr
P1
P2
P3
P4
P5
Next
Orig
Ind Ctr
React Date
L Let
St Adj
TA
PC Let