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DETERMINATION OF PEO STATUS OFFICE USE ONLY (Professional Employer Organization) State Form 52098 (R/12-06) Examiner INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT Approved 10 N. Senate Avenue Effective Date Indianapolis, IN 46204-2277 Date Completed Yes No Local: 317-232-7436 Toll Free: 1-800-8916499 Fax 317-233-2706 Supervisor For PEO Status approval complete this form with signature and return to IDWD with a copy of your PEO/Client contract template. PLEASE TYPE OR PRINT IN INK Federal ID Number: __ __ - __ __ __ __ __ __ __ Account Number Legal Name of Employing Unit ____________________________________________________________________ Trade Name (or d/b/a/) _____________________________________________________________________ Mailing Address ___________________________ City______________________ ZIP Code State____________ __ __ __ __ __ - __ __ __ __ Business Telephone Number Business Fax Number ( ( ) - ) Physical Address _________________________________ City______________________ State___________________ ZIP Code __ __ __ __ __ - __ __ __ __ Remarks - Enter the required information for owner, partners or officers. Please attach additional sheet(s) if needed. Name (please print) Title Social Security Number Telephone Number - - ( ) - - - ( ) - 1. Does your entity provide the non temporary, ongoing employee workforce REFERENCE of a client/clients under written agreement? 2. Does your entity pay the employees from its own bank account? Yes No PAGE/SECTION IN Yes No CONTRACT TEMPLATE Yes No 3. Does your entity have the right to hire and terminate the employees who Page perform services for the client? 4. Does your entity set the rate of pay for these employees, whether or not Section Page through negotiations with the client/clients? Yes No 5. Does your entity have direction and control over the employees, including Section Page corporate officers? Yes 6. Under written agreement with a client/clients do you assume responsibility for the unemployment insurance No Section coverage, file all required reports, contributions or reimbursements for liabilities and comply with IC §22-4, or other state and federal regulations relating to unemployment insureance on behalf of a client? 7. Page Yes Does your entity specialize in any particular business or industry? If Yes indicate type of business or industry: No Section Yes No Yes No Yes No ___________________________________________ 8 a. Does your entity have any common ownership interests with any of your client companies? b. Does your entity have any common officers with any of your client companies? c. Is your entity and/or any of the client companies operated in whole or in part by family members of either the entity or client companies? Yes If your answer is Yes to any of the three questions (a, b, or c), attach an additional sheet listing client companies. 9. Identification number under which you file Employers Quarterly Federal Tax Return (Form 941) No ___ -- _____________ 10. Attach a list of client companies providing other services to your entity. You must include the name of the company and the type of service performed (for example: accounting, bookkeeping, payroll, management, financial, legal or consulting services provided by the client to your entity.) 11. Enter any DWD account number previously assigned to you. __________________________________________ 12. Does your entity have a website? If so, please state address: ____________________________________________ 13. Is your entity advertised or listed in the telephone directory or other type of business directories and available to the public in general? Yes No Attach a sample 14. Do you provide only payroll services and/or benefit administrations for client entities and provide no other service? If no explain: ______________________________________________________________ Yes No 15. Common Paymaster is an arrangement (as further defined in IC § 22-4-6-3) under which an employee works for two or more related companies and the payroll for the employee is reported by one of the companies. Does your entity provide payroll services strictly for the purpose of acting as a common paymaster for federal tax reporting purposes? Yes No If no explain:_____________________________________________________________ I hereby certify that all information contained herein is true, correct and complete to the best of my knowledge and belief. ________________________________________ _______________________________________ Employer's Signature Prepared By Date ____________ Telephone Number ( ) ____ - ________ Date______________ Telephone Number ( ) ____ - _________