Nonprofit Unemployment Compensation

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Step 1 of 6

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Organization Profile

Organization Name*

Physical Address*

Street Address Address Line 2 City State ZIP

Contact*

First Last

Title*

Website*

Phone*

Fax*

Email*

Operations Profile

Type of Entity*

501c3

Government

Tribe

Date Established*

MM slash DD slash YYYY

When is your fiscal year?*

Description of Applicant's Operation*

Current UI Funding Method*

Paying State Unemployment Tax

Reimbursing (self-insured)

State Acct. No.*

FEIN*

If taxpaying:

Have you paid unemployment taxes for at least two years?

Yes

Are you currently in good standing with the state?

Yes

If reimbursing:

Current Management Method

Internal Staff

Third Party Administrator

Group Program

Current Administrator/Program (if applicable)

Employment Profile

Number of Full-Time Employees*

Number of Part-Time Employees*

Number of W-2s From Prior Year*

Do you anticipate any loss or reduction in overall revenue within your organization that will result in layoffs, and/or reduction in employees’ hours or wages within the next 12 months?*

Yes

If yes, please explain and include estimated number of affected employees and date(s) of action.

Do you anticipate any elimination or reduction of any revenue source(s) within your organization that will result in layoffs, and/or reduction in employees’ hours or wages within the next 12 months?*

Yes

If yes, identify the source and provide an explanation (include number of affected employees and date(s) of action).

Do you anticipate any restructuring within your organization that will result in layoffs, and/or reduction in employees’ hours or wages within the next 12 months?*

Yes

If yes, please explain and include estimated number of affected employees and date(s) of action.

Have you experienced any layoffs/staff reductions, other than regular seasonal during the last 12 months?*

Yes

If yes, please explain. Include number of affected employees and the dates on which layoffs or staff reductions took place.

Do you anticipate an increase in the hiring of employees who will be affected by seasonal layoffs over the next 12 months?*

Yes

If yes, please explain. Include number of employees and date(s) of action.

Are you currently or have you, in the past 12 months, had employees whose wages are exempt from unemployment?*

Yes

If yes, please explain. Include number of exempt employees and their term of employment.

How many of your employees are seasonal and when is their term of employment?*

How many of your employees are employed in a Head Start program and when is their term of employment?*

Please enter the following estimates:

Current YTD Gross Wages*

Current YTD UI Benefit Charges (claims paid)*

Current YTD UI Tax Rate (if applicable)*

Current YTD Annual Operating Budget*

Prior Year 1 Gross Wages*

Prior Year 1 UI Benefit Charges (claims paid)*

Prior Year 1 UI Tax Rate (if applicable)*

Prior Year 1 Annual Operating Budget*

Prior Year 2 Gross Wages*

Prior Year 2 UI Benefit Charges (claims paid)*

Prior Year 2 UI Tax Rate (if applicable)*

Prior Year 2 Annual Operating Budget*

Prior Year 3 Gross Wages*

Prior Year 3 UI Benefit Charges (claims paid)*

Prior Year 3 UI Tax Rate (if applicable)*

Prior Year 3 Annual Operating Budget*

Approximately how many claims do you have annually?*

Approximately how many of those claims are protested?*

Estimated Wages for Calendar Year 2022*

Funding Profile

What percentage of your annual payroll is attributable to the following funding sources:

Federal*

State*

City/County*

Fundraising or Operations*

Are there any upcoming funding issues, not previously mentioned on this application, specific to your organization or your sector that might affect your employment levels?

COVID-19

Has your organization entered into a Short Term Compensation Plan or Work Share Program since March 1, 2020?*

Yes

If yes, please provide a copy of the application submitted to the State.

Max. file size: 128 MB.

Provide changes and modifications

Has your organization applied for a Payroll Protection Program (PPP) Loan?*

Yes

If yes, were you approved?

Yes

If approved, when did your loan become effective?

Amount of loan

Has your organization been subject to any closures, furloughs or layoffs due to City, Federal or State Stay-at- Home Orders?*

Yes

If yes, what date was this effective?

MM slash DD slash YYYY

How many employees were impacted?

Have you recalled any previously furloughed or laid off employees?*

Yes

If yes, please provide number of employees recalled and date(s) of recall

Did any staff reject the offer to return to work?*

Yes

If yes, how many staff rejected the offer?

How did you hear about us?*

Insurance Agency

Nonprofit Association

Event

Website/Search Engine

Other

Please specify

Please specify website or search engine

Signature

The information provided on this application form has been confirmed by all necessary parties within this organization to be true, accurate, and complete to the best of our knowledge. We acknowledge that any misrepresentation will result in immediate cancellation of any service or coverage pursuant to the terms of this product for which this application is submitted.

Signature*

Please type full signature

Title

Date

MM slash DD slash YYYY