GEORGIA DEPARTMENT OF LABORSUITE 850 - 148 ANDREW YOUNG INTERNATIONAL BLVD NE - ATLANTA, GA 30303-1751EMPLOYER STATUS REPORTREAD INSTRUCTIONS BEFORE COMPLETION OF FORM1.ENTER OR CORRECT BUSINESS NAME AND ADDRESSAmerican LegalNet, Inc. www.FormsWorkFlow.com (CONTINUED)NATURE OF BUSINESS: Information is required on all items. Attach additional sheets, if necessary.A.How many Georgia locations do you operate?C.Enter in order of importance and indicateapproximate % of total annual income derived Provide the following information for each location, attaching additionalfrom each:sheets if necessary.Principal Service(s)Principal Product(s)B.Check the box that best describes the industry that relates to yourORMfg. Grown SoldRendered*business activities:Manufacturing%AgricultureTransportationForestry%Communication%FishingPublic Utilities* If Transportation-Trucking, indicate if interstate carrierMiningWholesale TradeD.Ifthisreportincludesestablishment(s)that onlyConstruction (specify):Retail Tradeperform services forotherunitsofthecompany,General ContractorsIndustrial%Financeindicate the primarytypeofserviceorsupportResidential% Commercial%Insuranceprovided. Check as many as apply:Speculative BuildingReal EstateSpecial Trade Contractor (specify plumbing,1.Central Administration3.Storage (warehouse)Servicesetc.,)2.Research,development,4.Other: (specify),Public AdministrationHeavy Construction (specify cable, highway,and testingPrivate Household etc.,)Employer FOR ASSISTANCE, call the Industry Classification Unit, (404) 232-3875IMPORTANT-Thisreportmustbefiled!Thelawprovidesthatallemployingunitsshallfileareportofitsemploymentduringacalendaryear.FortheSecurity Law,thisformhasassistyouinpurposeofaidingyouincomplyingwithOCGASection34-8-121oftheEmploymentbeenpreparedtofurnishingtherequiredinformation.Answerallquestionsfullyandifadditionalspaceisnecessaryunderanyitem,attachsignedanddatedsheetswhichbearthewords"SupplementtoFormDOL-1N."Eachfalsestatementorwillfulfailuretofurnish thisreport ispunishableasacrime. Each dayofsuchfailure or nrefusalconstitutesa separateoffense.TheGeorgiaEmployerStatusReportisrequiredofallemployershavingindividualsperformingservicesinGeorgiaregardlessofnumberordurationoftime.ThefilingofthisformisrequiredatthetimeyourbusinessfirsthadindividualsperformingserviceinGeorgia,orwhenyouacquiredanotherlegalentity,andmayalsoberequiredagainuponrequest.NOTE:Disclosureofyoursocialsecuritynumberismandatory.Itwillbeusedforthepurposeofidentificationanditisrequiredundertheauthorityof42U.S.C.Section405(c)(2)(C)andOCGASection 34-8-121.INSTRUCTIONS(NUMBERS CORRESPOND TO ITEMS ON FORM)Enterorcorrectnameandaddressofindividualowner,partners,corporationororganization.Thisistheaddresstowhichyouauthorizeusto1.mailallreports,correspondence,etc.IfyouhavealreadybeenassignedaGeorgiaDepartmentofLaborAccountNumber(Ga.DOLAcct.No)bythisDepartment,pleaseinsertthenumber.Indicatebycheckmarktypeoforganization.Ifanonprofitorganization,attachcopyofI.R.S.letterexemptingtheorganizationfromFederal2.IncomeTaxunderSection501(c)(3)ofInternalRevenueCode.3.Tradenamebywhichbusinessisknownifdifferentthan1.4.Physicallocationofbusiness,farmorhouseholdinGeorgiaifdifferentthan1.Pleaseincludetelephonenumberwithareacode.EnterthefirstdateofemploymentinGeorgiaandthefirstdateofGeorgiapayroll.5.IfyouaresubjecttotheFederalUnemploymentTaxAct,andarerequiredtofileFederalForm940,answerthisquestion"yes".Besuretoenter6.yourFederalEmployerIdentificationNumberwhetheranswered"yes"or"no".7.Answerthisquestionifyouacquiredthisbusinessfromanotheremployerorifafteryoubeganemployingworkersyouhaveacquiredotherbusinesses;mergedwithotherbusinesses;formedordissolvedpartnerships,corporations,professionalassociations;orifanyotherchangeintheownershipofthebusinesshasoccurred.Indicatethedateofacquisitionorchangeandprovideallinformationconcerningthepreviousowner'sname,tradename,addressandDOLAccountNumber.Indicatebycheckingtheappropriateblocktheportionofthepreviousowner'sbusinessinvolvedintheacquisitionorchange.Notransferofexperienceratinghistorycanbemadeunlessinformationconcerningthepreviousownerisprovided.PrivateBusinessEmployment-Mostemploymentisconsideredprivatebusinessemployment.Thisincludesalltypesofworkexceptdomestic8.servicesuchasmaids,gardeners,cooks,etc.,agriculturalserviceandserviceperformedforgovernmentalornonprofitorganizations.Domesticemploymentincludesallserviceforapersonintheoperationandmaintenanceofaprivatehousehold,localcollegecluborlocal9.chapterofacollegefraternityorsororitysuchaschauffeurs,cooks,babysitters,gardeners,maids,butlers,privateand/orsocialsecretaries,etc.Ifyouhadsuchemployment,consideronlycashpaymentsmadetoallindividualsperformingdomesticservicestodetermineif$1,000ormorecashwageswerepaidinanycalendarquarterduring1977andsubsequentquarters.10.Consideronlycashpaymentsmadetoallindividualsperformingagriculturalservicestodetermineif$20,000ormorecashwageswerepaidinanycalendarquarterduring1977andsubsequentquarters.AnswerthisquestiononlyifthisbusinessisanonprofitorganizationexemptfromFederalIncomeTaxunderSection501(c)(3)oftheInternal11.RevenueCode.AttachacopyoftheI.R.S.lettergrantingthisexemption.NonprofitorganizationswithtaxexemptionsotherthanunderSection501(c)(3)shouldanswerquestion8,PrivateBusinessEmployment.12.Self-explanatory.FOR ASSISTANCE, call the Adjudication Section, (404) 232-3301RETURN ORIGINAL WITHIN TEN (10) DAYS TO:ORFAX TO:Georgia Department of LaborAdjudication SectionP O Box 740234404-232-3285 Atlanta, GA 30374-0234Please RETAIN a copy for your files. 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