FOR DIVISION USE ONLY Massachusetts Department of Workforce Emp. No.: Subj. Date: Division of Unemployment Assistance Reason: Qtr.: Development EMPLOYER STATUS REPORT No. Employees: Area: Rate Yr: NAICS: Org.: Complete And Return This Form Within 10 days To: Division of Unemployment Assistance Status Department - 5th Floor 19 Staniford Street Boston, MA 02114-2589 13th Wk.: %Transfer Aux: Workforce Training Yr./Rate Deter. By: Pred. No.: Contribution Yr./Rate 1. 1. 2. 2. ESR Status: 3. 3. Fax: (617) 727-8221 Leasing Code: 4. 4. THIS FORM IS FOR USE BY NEW AND EXISTING EMPLOYERS Employer Type: 5. 5. Pred. Date: PLEASE TYPE OR PRINT CLEARLY IN INK. Pred. Cd.: CALL (617) 626-5075 FOR ASSISTANCE. SECTION I ALL FIELDS REQUIRED 1. Name of employing unit: 2. Trade name: 3. List ALL business locations in Massachusetts. If more than one, attach a separate sheet. No. Street (do not use P.O. box number) City State 4. Mailing address: 5. Payroll Records Address: 6. Business phone: Zip Code 7. Federal Identification #: 8. Owner, partners or officers: Name (Required) S.S.A. No. (Required) Home address Are officers compensated for their services? Title n Yes n Yes n Sole Proprietor n Trust n Partnership n LLC (single member) If corporation: date incorporated 10. First date of employment in Massachusetts: n Corporation n LLC (corp.) n No n Yes 9. Type of organization: n No n No n Other (specify) n LLC (partnership) state incorporated 11. Describe nature of your company's business/industry: 12. Name your principle commodity, product or service 13. Are you a client of an employee leasing company? Please attach a copy of your contract. n Yes n No If Yes Name and Address of Leasing Company. 14. Are you liable for federal unemployment tax? n Yes n No First date of liability : 15. If your main activity in Massachusetts is to provide support services to other locations of your company, please check appropriate box: n Headquarters n Research n Warehouse n Computer Center n Other (specify) 16. Do you hold an exemption from federal income taxes as a non-profit organization described under section 501 (c)(3) of the Internal Revenue Code? n Yes n No If Yes, please attach a copy of your exemption with this report. 17. Have you previously been subject to the Massachusetts Unemployment Insurance Law? If yes, give DUA Account Number Name Form 1110-A Rev. 07-19-07 Commonwealth of Massachusetts n Yes n No Page 1 of 8 American LegalNet, Inc. www.FormsWorkflow.com SECTION II PLEASE REFER TO INSTRUCTIONS TO COMPLETE THIS FORM You must answer "yes" if any of the following apply: You acquired All or Part of another business or organization operating in MA; you were part of a merger with (or consolidation of) a business operating in MA; you changed your Federal Identification Number; you have had a relationship with or are a "spin-off" of a company registered with MA DUA; you changed organizational structure. This includes any changes from one business type to another (examples include—but not limited to—changes from a sole proprietorship to corporation, LLC, LLP, etc., or from a corporation to a sole proprietor, partnership, LLP Trust, etc). 1. Have you undergone any type of organizational change? n Yes n No If no proceed to Section III 2. What was the nature of the organizational change in Massachusetts? n Acquisition n Merger n Consolidation n Transfer of Employees only n Other (please explain) 3. What is the date of the business transfer or organizational change? (mm/dd/yy) 4. Predecessor DUA account number: 5. Predecessor FEIN 6. Name of predecessor: 7. Did you acquire the assets of the predecessor's business? n Yes n No 8. Did you acquire all or part of the predecessor's business? n All n Part If part, please explain: 9. Please check major assets acquired: n Place of business n Workforce n n Customers n Goodwill n Franchise rights n Trade name n Stock n Other n Accounts receivable n Tools, fixtures, equipment, furniture License 10. Did you continue the operation of business that you acquired? n Yes n No 11. Brief summary of business reason(s) for this acquisition 12. Will the predecessor remain in business in Massachusetts? n Yes n If yes, list the present Massachusetts location of the predecessor. If yes, state the number of employees to remain with predecessor in Massachusetts after the date of succession. No If no, please give the date of the predecessor's final payroll. (mm/dd/yy) 13. Has the predecessor employer filed all quarterly reports and paid all contributions, interest, and penalties due to this Agency? n Yes n SECTION III No n Unknown PLEASE SELECT WHICH EMPLOYMENT TYPE LISTED BELOW BEST DESCRIBES YOUR BUSINESS 1. DOMESTIC EMPLOYERS (Services performed in the home such as: gardener, personal care attendant, baby sitter, housekeeper, etc.) Did you pay $1,000 or more in cash remuneration in any calendar quarter during the current or preceding calendar year for domestic services? n Yes n No 2. AGRICULTURAL EMPLOYERS (Services performed on a farm including stock, dairy, poultry, fruit, fur bearing animals, and truck farms, plantations, ranches, nurseries, ranges, orchards, greenhouses, and other similar structures that are used primarily for raising of agricultural and horticultural commodities.) Did you pay $20,000 or more in cash remuneration for agricultural services during any calendar quarter of the current or preceding calendar year? n Yes n No Did you employ 10 or more individuals on some day in each of 20 calendar weeks, not necessarily consecutive, in either the current or preceding calendar year? n Yes n No If you do not meet the agricultural requirements but have a farm-based retail operation that includes the sale of items other than those produced on your farm, you are not an agricultural employer. Please proceed to question #3 (all other employers). Form 1110-A Commonwealth of Massachusetts Page 2 of 8 American LegalNet, Inc. www.FormsWorkflow.com 3. ALL OTHER MASSACHUSETTS EMPLOYERS Did you pay wages of $1,500 or more in any calendar quarter in either the current or preceding calendar year? n Yes n No Did you employ one or more individuals on some day in each of 13 weeks, not necessarily consecutive, in either the current or preceding calendar year? n Yes n No 4. OUT-OF-STATE EMPLOYERS Did you have a MASSACHUSETTS payroll in excess of $200? n Yes n No 5. PLEASE DO NOT SUBMIT UNTIL YOU ARE ABLE TO DOCUMENT ACTUAL GROSS WAGES PAID PER THE ABOVE REPORTING CRITERIA List below the number of individuals in your employment in Massachusetts within each calendar week. Include full and part-time employees, also paid officers, if corporation. An individual sole proprietor or a partner should not be counted as an employee. Show total Massachusetts payroll for each calendar quarter. This application cannot be processed with estimated or anticipated future wages. If this application is not completed in full it will be returned to you for the required information (i.e.: number of employees, dates of employment, gross wages). RECORD OF MASSACHUSETTS EMPLOYMENT CURRENT CALENDAR YEAR PRECEDING CALENDAR YEAR PRECEDING CALENDAR YEAR Enter Year ___________________ Total Wages 1st QTR ___________ 2nd QTR ___________ Enter Year __________________ Total Wages 1st QTR ___________ 2nd QTR ___________ Enter Year _____________________ Total Wages 1st QTR ___________ 2nd QTR ___________ JANUARY APRIL JANUARY APRIL JANUARY APRIL FEBRUARY MAY FEBRUARY MAY FEBRUARY MAY MARCH JUNE MARCH JUNE MARCH JUNE Total Wages 3rd QTR ___________ 4th QTR ___________ Total Wages 3rd QTR ___________ 4th QTR ___________ Total Wages 3rd QTR ___________ 4th QTR ___________ JULY OCTOBER JULY OCTOBER JULY OCTOBER AUGUST NOVEMBER AUGUST NOVEMBER AUGUST NOVEMBER SEPTEMBER DECEMBER SEPTEMBER DECEMBER SEPTEMBER DECEMBER Week Ending Number Employed Week Ending Number Employed Week Ending Number Employed Week Ending Number Employed Week Ending Number Employed Week Ending Number Employed Form 1110-A Commonwealth of Massachusetts Page 3 of 8 American LegalNet, Inc. www.FormsWorkflow.com CERTIFICATION If you answered yes to Question 1 in Section II and if this organizational change involves companies with any commonality in ownership, management and/or control, you must proceed to Section IV. If not, please complete the certification below. Massachusetts law provides for civil fines and criminal penalties for misrepresentation, evasion, willful nondisclosure, and failure or refusal to furnish reports or requested information to this agency. Both the employer of record or the agent, who knowingly advises in such a way that results in a violation of these provisions, shall be subject to said penalties. (MGL Ch 151A, Section 14N). Failure to comply with all reporting and payment requirements under MGL Chapter 151A may result in loss of your organization’s right to operate or renew your license by the Commonwealth of Massachusetts. THIS REPORT MUST BE SIGNED BY THE OWNER, PARTNER, OR CORPORATE OFFICER CERTIFICATION I certify, under penalties of law, that all statements made hereon are true to the best of my knowledge and belief. Name of Employing unit: Date: Signature: Title: Name: (Print) PREDECESSOR CERTIFICATION I hereby certify that all information submitted by the successor is true in accordance with the transfer. Name of Predecessor Company: Date Signature: Title Name: (Print) Form 1110-A Commonwealth of Massachusetts Page 4 of 8 American LegalNet, Inc. www.FormsWorkflow.com DO NOT COMPLETE COMMON OWNERSHIP SECTION UNLESS TRANSFERS OCCURRED ON OR AFTER JANUARY 1, 2006. SECTION IV PART A COMMON OWNERSHIP To be completed by the TRANSFEREE employer initiating the change. Please note that by signing this document the transferring employer must attest to these answers. (Transferee employer- one to whom a conveyance of title or property is made; a person/entity to whom something is transferred or conveyed. Example, Company B acquires part or all of the business of Company A. In this example Company B is the transferee employer and Company A is the transferring employer or transferor). Yes n No If yes, are the transferee employer and the transferring employer subsidiaries of the same Parent Company? n Yes Is the transferee employer the Parent Company or a subsidiary of the transferring employer? n If yes, please list the name of the Parent Company and FEIN# Name: FEIN: n No If yes, please list the name of the Parent Company and FEIN# Name: FEIN: PLEASE CHECK OFF WHICH ORGANIZATIONAL TYPE BEST DESCRIBES YOUR BUSINESS AND ANSWER THE QUESTIONS LISTED FOLLOWING THAT ORGANIZATION TYPE: 1. ORGANIZATIONAL TYPE n CORPORATION (includes Limited Liability Companies (LLC) organized as a corporation) Is there a person, corporation or other legal entity that serves in the capacity of Chief Financial Officer (CFO), Chief Executive Officer (CEO) or other similar authority for the transferring employer who also serves as the CFO or CEO or other person holding similar authority for the transferee employer? n Yes n No If yes, list the name/entity, SS#/FEIN and title below Name SS# Title If Entity acts as CFO/CEO: Company Name: FEIN# Does either the transferee or the transferring employer exercise power indirectly or directly through one or more persons of over 25% or more of any voting securities of BOTH the transferring employer and the transferee? n Yes n No If yes, list the name/entity, FEIN and the percentage of ownership Name/Entity % of ownership SS# FEIN# Does the CFO, CEO or other person holding similar authority for the transferring employer have a familial relationship with the CFO, CEO or other person holding a position of similar authority for the transferee employer? n Yes n No If yes, please list name, SS#, (title and relationship) Name SS# Title Relationship Name SS# Title Relationship 2. n SOLE PROPRIETOR (includes LLCs organized as a single member) Does the transferee employer's sole proprietor/owner have a familial relationship to the transferring employer's sole proprietor/owner? (Family member is defined but not limited to spouse, child, parent, sister, brother, sister-in-law, brother-in-law, aunt, uncle, niece, nephew, and first cousin.) n Yes n No If yes, please list name, SS# and relationship Name SS# Relationship Name SS# Relationship Form 1110-A Commonwealth of Massachusetts Page 5 of 8 American LegalNet, Inc. www.FormsWorkflow.com 3. n PARTNERSHIPS, JOINT VENTURES (includes LLP, LLC organized as a partnership) Is there a person, corporation or other legal entity that serves in the capacity of a managing partner in both the transferring employer and the transferee employer? n Yes n No If yes, please list name/entity, SS# /FEIN# and title Name SS# Title If Entity acts as Managing Partner: Company Name: FEIN# Does a partner for the transferring employer have a familial relationship to any partner, member or other person holding a position of authority for the transferee employer? n Yes n No If yes please list name, SS#, title and relationship Name SS# Title Relationship 4. n TRUST Does one person, corporation or other legal entity serve as a trustee of the transferring trust, either directly or through an intermediary, and also serve as a trustee in the transferee trust, or as a beneficiary of the trust? n Name Yes n No SS# Title If Entity serves as trustee: Company Name: FEIN# If you answered yes to any of the above questions, please complete Section IV Part B SECTION IV PART B COMMON OWNERSHIP Complete the following: 1. The business address of your corporate HQ: 2. Name of business transferred: 3. Transferor’s DUA account number: 4. Transferor’s business location: 5 Date of transfer: 6. Number of workers employed by transferor in Massachusetts just before the sale 7. Number of workers employed by you, the transferee, in Massachusetts just before the sale 8. after the sale after the sale How many of the transferor workers have you continued to employ? have you NOT continued to employ? You must complete Section IV Part C if you took over part of another business operating in Massachusetts SECTION IV PART C PART SUCCESSIONS 9. Is the transferor still doing business in MA? n Yes n No n Unknown If yes what business activities are continued? (Note: Transferee may become liable for some or all of any DUA delinquency of the transferor) This application must be accompanied by a schedule showing the name and social security number of each individual associated with that portion of the business being transferred, regardless of whether or not they are actually transferred to the transferee employer. Form 1110-A Commonwealth of Massachusetts Page 6 of 8 American LegalNet, Inc. www.FormsWorkflow.com  ALL WAGE INFORMATION IN CHARTS A AND B ON THIS FORM. DO NOT JUST ATTACH PREVIOUSLY FILED PLEASE SUMMARIZE FORMS 1. IN ADDITION, PLEASE COMPLETE EVERY APPLICABLE ITEM ON THIS FORM. FAILURE TO DO SO COMPLETELY, ACCURATELY, AND IN A TIMELY MANNER MAY RESULT IN PENALTIES FOR FAILURE TO COMPLY WITH THE LAW, AS PROVIDED FOR UNDER MGL, CH 151A, SECTION 14N. Please provide, in Chart A, the transferring employer’s entire payroll for the last 4 completed quarters prior to the transfer date. In Chart B, provide the transferring employer’s payroll for that portion acquired for the last 4 completed quarters prior to the transfer date. Please provide dates of quarters (mo, day, yr) to which you are referring in the charts below. EXAMPLE Date transfer took place: 04/01/06 Chart A PLEASE PROVIDE TOTAL WAGES FOR ALL EMPLOYEES OF THE TRANSFERRING EMPLOYER FOR THE LAST 4 COMPLETED QUARTERS PRIOR TO THE TRANSFER DATE. PLEASE START WITH THE MOST RECENT QUARTER AND WORK BACK IN TIME. Quarter dates Total Wages Excess Wages (1/01/06-3/31/06) $ 60,000 $ 0.00 (10/01/05-12/31/05) $ 75,500 $ 67,500 (7/01/05-9/30/05) $ 67,500 $ 61,000 (4/01/05 -6/30/05) $ 67,500 $ 8,000 12 Month Summary $ 270,500 $ 136,500 $ 7,500 $ 6,500 $ 59,500 $ 133,500 (wages over $14,000 wage base per employee) Taxable Wages $ 60,000 Number of employees 8, 8, 8 10, 10, 10 9, 9, 9 9, 9, who worked during or received pay for the payroll period which includes the 12th day of the month. 9 Chart B PLEASE PROVIDE WAGE DETAIL FOR THAT PORTION ACQUIRED OF THE TRANSFERRING EMPLOYER'S PAYROLL FOR THE LAST 4 COMPLETED QUARTERS PRIOR TO THE TRANSFER DATE. PLEASE START WITH THE MOST RECENT QUARTER AND WORK BACK IN TIME. Quarter dates Total Wages Excess Wages (1/01/06-3/31/06) $ 37,500 $ 0.00 (10/01/05-12/31/05) $ 30,000 $ 30,000 (7/01/05-9/30/05) $ 37,500 $ 37,500 (4/01/05 -6/30/05) 12 Month Summary $ 37,500 $ 142,500 $ 5,000 $ 72,500 (wages over $14,000 wage base per employee) Taxable Wages $ 37,500 $ 0.00 $ 0.00 $ 32,500 $ 70,000 Number of employees 4, 4, 4 5, 5, 5 5, 5, 5 6, 6, 6 who worked during or received pay for the payroll period which includes the 12th day of the month.. Chart A Date transfer took place: PLEASE PROVIDE TOTAL WAGES FOR ALL EMPLOYEES OF THE TRANSFERRING EMPLOYER FOR THE LAST 4 COMPLETED QUARTERS PRIOR TO THE TRANSFER DATE. PLEASE START WITH THE MOST RECENT QUARTER AND WORK BACK IN TIME. ( / / - / / ) Quarter dates ( / / - / / )) / / - / / ( / / - / / ) ( / / - // // ) ) / - Total Wages $ $ $ $ $ Excess Wages $ $ $ $ $ $ $ $ 12 Month Summary $ (wages over $14,000 wage base per employee) Taxable Wages $ , , , , , , Number of employees who worked during or received pay for the payroll period which includes the 12th day of the month. , , Chart B PLEASE PROVIDE WAGE DETAIL FOR THAT PORTION ACQUIRED OF THE TRANSFERRING EMPLOYER'S PAYROLL FOR THE LAST 4 COMPLETED QUARTERS PRIOR TO THE TRANSFER DATE. PLEASE START WITH THE MOST RECENT QUARTER AND WORK BACK IN TIME. ( // // -- // // )) Quarter dates ( // // -- // // ) ) ( / / - / / ) - / ( // // - / / ) Total Wages $ $ $ $ $ Excess Wages $ $ $ $ $ $ $ $ 12 Month Summary $ (wages over $14,000 wage base per employee) Taxable Wages $ , , , , , , Number of employees who worked during or received pay for the payroll period which includes the 12th day of the month. Form 1110-A Commonwealth of Massachusetts , , Page 7 of 8 American LegalNet, Inc. www.FormsWorkflow.com  CERTIFICATION Massachusetts law provides for civil fines and criminal penalties for misrepresentation, evasion, willful nondisclosure, and failure or refusal to furnish reports or requested information to this agency. Both the employer of record or the agent, who knowingly advises in such a way that results in a violation of these provisions, shall be subject to said penalties. (MGL Ch 151A, Section 14N). Failure to comply with all reporting and payment requirements under MGL Chapter 151A may result in loss of your organization’s right to operate or renew your license by the Commonwealth of Massachusetts. THIS REPORT MUST BE SIGNED BY THE OWNER, PARTNER, OR CORPORATE OFFICER AUTHORIZED TO BIND THE CORPORATION. SUCCESSOR CERTIFICATION I certify, under penalties of law, that all statements made here on are true to the best of my knowledge and belief. Name of Employing unit; Date: Signature: Title: Name (Print): PREDECESSOR CERTIFICATION I hereby certify that all information submitted by the successor is true in accordance with the transfer. Name of Predecessor Company: Date Signature: Title Name: (Print) Form 1110-A Commonwealth of Massachusetts Page 8 of 8 American LegalNet, Inc. www.FormsWorkflow.com