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)?

2 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?

3 :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?

4 General employers :Has this business had a total gross payroll of $1,500 or more in a calendar quarter?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?

5 (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?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?)

6 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.