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School entity *

Contact name *

First

Last

Phone *

Email *

Total number of employees with wages more than $10,000 *

Tax Collectors are NOT eligible for Unemployment Compensation and should not be included in above number.

Total number of employees with wages less than $10,000 *

Tax Collectors are NOT eligible for Unemployment Compensation and should not be included in above number.

Total wages paid to employees with less than $10,000 *

Tax Collectors are NOT eligible for Unemployment Compensation and should not be included in above number.

Please upload documentation for above figures *

Drag & Drop Files, Choose Files to Upload

Please combine documents into one PDF document

Please Note: If you use the CSIU Payroll System, there are two reports set up that will provide the information needed:

Unemployment Comp/File (this is a detailed report; the last page shows totals and must be run by quarter) report tag pyucqtr - you need to select "print reports only." Return a copy of the last page showing totals for each quarter in 2023 and list the number of total employees for each quarter.
Unemployment Comp/PSBA report tag pyucpsba. Attach a copy of this report. This shows the $10,000 cap payroll as well as the employee count.

Please upload copies of the 941 Federal Wage Summary Pages for all 4 quarters of the 2023 year *

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

2023 Calendar Year

Please upload any additional documents as needed

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Do you anticipate any restructuring or reduction of revenue sources resulting in layoffs in the upcoming school year (2024-2025)?

Yes
No

Have you experienced any staff reductions, other than regular seasonal, in the last 36 months?

Yes
No

What services do you currently outsource?

Please describe your other outsourced services.

What services do you anticipate outsourcing in the upcoming school year (2024-2025)?

Please describe your other outsourced services.

Terms and Conditions - 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 misrepresenation will result in immediate cancellation of service. *

I Agree

Signature *

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