REQUEST INFORMATION

UNEMPLOYMENT COST CONTROL INFORMATION REQUEST

*Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:		Zip:
Phone:		Fax:
*E-mail:
How many people do you currently employ?
How many W-2's did you issue this past year?
Is your organization tax rated or reimbursing? Tax Rated Reimbursing
If you reimburse, how many benefits were paid out in the last three years?

If you are tax rated, please fill in the following data taken from your Annual State Unemploment Insurance Notice:
Current tax rate:
Total Benefits Paid in previous year?
Total Taxable Payroll for last year:
Comments:
Fields Marked with * are Required