Professional Employer Organization Request for Registration PEO-1

Professional Employer Organization Request for Registration

PEO-1
Instructions and List of Forms for Professional Employer Organization (PEO) or Professional Employer Organization Group (PEO Group)

This form must be completed and printed by the applicant. The printed form should then be mailed per the instructions detailed within this Knowledge Base article.

Please ensure that any of the other required documents/statements for your application are included and mailed at the same time.
A. Type of Request (Check One)
Individual Professional Employer (PEO)
Professional Employer Organization Group (PEO Group)
B. General Information
Name of individual PEO or of parent organization (applicant) that has majority ownership of all members of the group:
Additional names, if any, under which the PEO currently conducts business:
Type of business organization (Check one):
CT State Tax ID Number:
CT Unemployment Insurance Employer Registration Number:
Federal Employer Identification Number (FEIN):
Address (Principal Administrative Office):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number (Principal Administrative Office):

Area CodePhone Number
Telephone Number (Principal Administrative Office):

Area CodePhone Number
Email (Principal Administrative Office):
example@example.com
List the current address of each additional office the individual PEO or parent organization maintains in Connecticut:
Fiscal year starts:

MonthDayYear
Fiscal year ends:

MonthDayYear
C. PEO Ownership Information
Provide information of any person that individually or acting in concert with one or more other persons, owns or controls or will control, directly or indirectly, 25% or more of the equity interest of the Applicant.
1. Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number:
Title:
% of Voting Interest:
List below evidence of business experience for the last four years for each person listed above, identify management and supervisory positions, including President, Chief Executive Officer and person with authority to act as senior
executive officer.
Employer:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date from:

MonthDayYear
Date to:

MonthDayYear
Employer Phone Number:

Area CodePhone Number
Brief Description of Responsibilities:
Add another owner?
2. Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number:
Title:
% of Voting Interest:
List below evidence of business experience for the last four years for each person listed above, identify management and supervisory positions, including President, Chief Executive Officer and person with authority to act as senior
executive officer.
Employer:
Date from:

MonthDayYear
Date to:

MonthDayYear
Employer Phone Number:

Area CodePhone Number
Brief Description of Responsibilities:
Add a third owner?
3. Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number:
Title:
% of Voting Interest:
List below evidence of business experience for the last four years for each person listed above, identify management and supervisory positions, including President, Chief Executive Officer and person with authority to act as senior
executive officer.
Employer:
Date from:

MonthDayYear
Date to:

MonthDayYear
Employer Phone Number:

Area CodePhone Number
Brief Description of Responsibilities:
2. List by jurisdiction each name under which the applicant has operated in the preceding 5 years, including any alternative names, names of predecessors, the name of the immediate successor business entity and, if known, any other successor business entities.:
D. List of All Clients of the PEO or PEO Group
This form allows input of up to three client companies. Please use a separate sheet of paper if needed to list all client companies.

For each client company include:
- Client company name
- Client company address (physical location)
- Client company state tax ID number, and
- Connecticut Unemployment Insurance Employer Registration Number
Client Company Name:
Client Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company Sales Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
Add another Client Company
Client Company Name:
Client Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company Sales Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
Add third Client Company:
Client Company Name:
Client Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Company Sales Tax ID Number:
Connecticut Unemployment Insurance Employer Registration Number:
E. Financial Statements
For PEO or PEO group that has conducted business prior to January 1, 2009 and has working capital of $150,000, complete Attestation of Financial Statement and include the most recent audit that was conducted no earlier than 13
months prior to the date of application (PEO-2)

For PEO or PEO group that has not had sufficient operating history to have audited financial statements based on at least 12 months of operating history, complete Attestation of Financial Statement for an applicant that has not had sufficient
operating history to have audited financial statements based on at least 12 months of operating history. (PEO-3)

If this is a renewal, please submit the audit for the preceding fiscal year and notice of any changes in the information provided in the applicant’s immediately preceding application. (PEO-2)

In lieu of the above financial statements, the Professional Employer Organization or Professional Employer Organization Group shall provide a bond, irrevocable letter of credit or securities with a minimum market value of $150,000 to the
department. (PEO-8)
F. Group Information (To be completed only by Group Applicants)
List all the Professional Employer Organizations in the group. Include the FEIN and address for each PEO. Use additional paper if necessary.

This form allows input of up to three PEO. Please use a separate sheet of paper if needed to list all PEO.
PEO
FEIN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add another PEO:
PEO
FEIN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add a third PEO?
PEO
FEIN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Information
1. Additional names, if any, under which the PEOs conduct business:
2. List the addresses of each additional office each member of the group maintains in Connecticut:
3. Other than the addresses listed in #2, list the addresses of each office maintained by each member of the group in Connecticut during the past five years. Include any other names used and names of predecessors and successors, if known. Use additional paper if necessary:
4. The group may satisfy the reporting and financial requirements on a combined or consolidated basis provided each member of the group guarantees the obligations under Section 31-221a et seq. of the Connecticut General Statutes of each member of the group. (PEO-6):
Should be Empty:

Professional Employer Organization Request for Registration

A. Type of Request (Check One)

B. General Information

C. PEO Ownership Information

D. List of All Clients of the PEO or PEO Group

E. Financial Statements

F. Group Information (To be completed only by Group Applicants)

Additional Information