COMMONWEALTH of VIRGINIA

1 Page 1 of 2 COMMONWEALTH of VIRGINIAV irginia Employment CommissionEqual Opportunity Employer/Program Auxiliary Aids and Services Are Available Upon Request to Individuals with DisabilitiesMost services available at (804) 786-7159 | Fax: (804) 786-5890 VUIS-10-27-2015T-FC-27-2 Report to Determine Liability (T-FC-27)AccountNumber:Federal IDNumber:Tired of paperwork? We can help!Make Changes to yourUnemployment Insurance tax account 's fast, easy, accurate, and secure! to:VECAttn: Employer Box 1358, Richmond, VA 23218-1174 Type of Organization:SoleProprietorIndividualCor porationLLCLLPG eneralParternshipGovernmentLimitedPartne rshipOther_____State of Incorporation or Formation:Are you a Professional EmployerOrganization(PEO)? YesNoIf yes, attach a list of all clients containing clientname, address, Fed ID#, and contract begin Name:Doing Business As:Attention:Business Mailing Address:Address 1:Address 2:City:State:ZipCode:County:PhoneNumber: Fax Number:Business Location Address:(If more than one VA location, attach list of other addresses)Select one of the following: Physical Location Employee Residence Job/WorksiteAddress 1:Address 2:State:ZipCode:Name the VIRGINIA CITY or VIRGINIA COUNTY in which the business is located (Specify location where work is actually performed)Locality Name: City CountyIs this business base of operation in a state other than VIRGINIA ; and is this business involved in building or road construction?

2 :YesNoDo you have any workers who performservicesfor your business whom you consider to be self-employed or independent contractors?YesNoDescribe in detail mainbusiness activity in VIRGINIA :When did you first haveemployees working in VIRGINIA :Number of employeesworking in VIRGINIA :Has this business previously been liable underthe Federal Unemployment Tax Act (FUTA)?YesNoIfYes, enter datePage 2 of 2 Equal Opportunity Employer/Program Auxiliary Aids and Services Are Available Upon Request to Individuals with DisabilitiesMost services available at (804) 786-7159 | Fax: (804) 786-5890 VUIS-10-27-2015T-FC-27-3 Report to Determine Liability (T-FC-27)Account Registration-ContinuedChoose an employment type and complete all associated questions:If yes, on what date?General Employers:Has this business had a total gross payroll of $1,500 or more in a calendar quarter?

3 YesNoHas the business had one or more employees for some portion of a day in each oftwenty (20) different weeks (not necessarily consecutive) in a calendar year?YesNoAgricultural Employers:Has this business had a total gross payroll of $20,000 or more in a calendar quarter?YesNoHas this business had ten (10) or more employees for some portion of a day in eachof twenty (20) different weeks (not necessarily consecutive) in a calendar year?YesNoDomestic Employers:Has this business had a total gross payroll of $1,000 or more in a calendar quarter?YesNoIndicate the method you elect to file and pay taxes:QuarterlyAnnuallyNon-Profit Employers:Is your Organization Exempt from Tax as described in 501(c) (3) under Section501(a) of the IRS Code?(Attach IRS letter as documentation)YesNoHas this business had four (4) or more employees for some portion of a day in eachof twenty (20) different weeks (not necessarily consecutive) in a calendar year?

4 YesNoIf No is selected, do you wish to voluntarily cover your employees per Government or 501(c)(3) employer (Indicate the method you elect to pay taxes):TaxableReimbursableDid you acquire any of the organization, trade, business,employees or any assets of another VIRGINIA employer:YesNoIfYes, did you acquire:AllPartNature of Acquisition IfPart,what %was acquired?Select one of the following:Purchase ofOrganizationChange of EntityDeath of ProprietorChange in Fed. ID NumberSpin-Off of SubsidiaryCorporate Change orReorganizationPartnership Change orReorganization(50% orMore Partners ChangedOther_____Is there common ownership management or control between the predecessor and successor?YesNoName of organization acquired:Predecessor's VECA ccount Number:FEIN:Dateacquired:Responsible Party: (if more than one responsible party, attach list)Name:SSN:Title:EmailAddress:Residen ceAddress:City:State:ZipCode:PhoneNumber : CertificationI certify that the information contained in this report, required bythe Viginia Unemployment Compensation Act, is true and Contact s Name, Title andphone numberContact EmailAddress.)