Outline
The New York LS 665 form is a crucial document for Professional Employer Organizations (PEOs) seeking to operate in the state. This form facilitates both initial and renewal requests for registration, ensuring compliance with New York's labor laws. Applicants must indicate whether they are applying as an individual PEO or as part of a PEO group. The form requires general information about the organization, including its name, type of business, and contact details. Additionally, ownership information must be disclosed, detailing individuals or entities with significant ownership stakes. For group applicants, the form includes sections to list all member PEOs and their respective addresses. Submission instructions guide applicants through the process, specifying necessary attachments such as financial statements and proof of insurance. Compliance with ongoing responsibilities, including quarterly tax certifications and client lists, is also outlined. The form concludes with a declaration that affirms the applicant's commitment to legal compliance and accuracy of the provided information.
Sample - New York Ls 665 Form
Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, NY 12240
Professional Employer Organization
Request for Registration
A. Type of Request (check one)
Initial |
Renewal for an individual Professional Employer Organization (PEO) |
Initial |
Renewal for a PEO Group (two or more PEOs that are majority owned by the same entity). |
B. General Information (to be completed by individual and group applicants)
1a. Name of individual PEO or of parent organization (applicant) that has majority ownership of all members of the Group:
1b. Additional names, if any, under which the PEO currently conducts business:
2.Type of business organization (check one)
Corporation |
Sole Proprietorship |
Limited Liability Partnership
Partnership |
Limited Liability Company |
3.Federal Employer Identification Number (FEIN): __ __ - __ __ __ __ __ __ __
4a. Complete physical address of Principal Administrative Office:
4b. Mailing address, if different:
4c. Telephone, fax, and
Fax:
5a. List the current address of each additional office the individual PEO or parent organization maintains in New York. Use separate sheet of paper if necessary.
5b. Other than those in 5a., list the addresses of each office you maintained in New York during the past five years. Include any other names used and names of any predecessors and successors, if known. Use additional paper if necessary.
6. Fiscal year starts |
and ends |
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LS 665 (06/20) |
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Page 1 of 4 |
C. Ownership Information (to be completed by individual and group applicants)
1a. If the applicant PEO is privately or closely held, list all persons or entities that own a five percent (5%) or greater interest in the individual PEO or the parent organization of the PEO group at the time of this application. Use additional paper if necessary.
Person or Entity |
% Ownership |
Address |
1b. List all persons not listed above that have owned a five percent (5%) or greater interest in the individual PEO or the parent organization of the PEO group in the five years preceding the date of this application. Use additional paper if necessary.
Person or Entity |
% Ownership |
Address |
2.If the applicant PEO or its parent company is a publicly traded company, list all persons or entities that own fifty percent (50%) or greater interest in the PEO or the parent company of the PEO.
Person or Entity |
% Ownership |
Address |
D. Group Information (to be completed only by group applicants)
1a. List all the Professional Employer Organizations in the group. Include the FEIN and address for each PEO. Use additional paper if necessary.
PEO |
FEIN |
Address |
1b. Additional names, if any, under which the PEOs conduct business.
2a. List the addresses of each additional office each member of the group maintains in New York. Use separate sheet of paper if necessary.
2b. Other than those in 2a., list the addresses of each office maintained by each member of the group in New York during the past five years. Include any other names used and names of predecessors and successors, if known. Use additional paper if necessary.
LS 665 (06/20) |
Page 2 of 4 |
E. Submission Instructions (applicable to individual and group applicants)
•For any questions, email [email protected] or call (518)
•The initial PEO registration application must be submitted prior to operating in New York State. Renewal registration application(s) must be submitted no later than 180 days after the end of the PEO’s fiscal year.
•Make sure you have marked on the first page whether this is an initial or renewal request by an individual PEO or a PEO Group, and the Declaration and Group Guaranty, if applicable, on the next page are completed.
•With an initial request, submit a copy of the corporate filing receipt and/or authorization to do business in New York State from the New York State Secretary of State for each incorporated individual PEO, parent organization and PEO group member.
•Attach a blank client contract incorporating the requirements of Article 31 of the New York Labor Law and a sample written notice to worksite employees.
•Attach a list of all New York clients including the name, address, FEIN, type of business, name of the New York State Workers’ Compensation and Disability Insurance policyholders, and number of employees for each client. This list will be kept confidential. Attach a reviewed or audited financial statement of the PEO’s most recent fiscal year;
o The statement must have been prepared within 180 days prior to the submission by an independent certified public accountant (CPA) using generally accepted accounting principles (GAAP) and must show a minimum net worth of $75,000.
o The statement must be accompanied by a cover letter, signed by the independent CPA, certifying that (1) the statement fairly represents the financial position of the firm in accordance with GAAP and (2) there is reasonable assurance that the firm has timely paid all applicable federal and state payroll taxes on all New York employees (for example: office, worksite, etc.) for that fiscal year and explaining the basis for these certifications.
o A PEO Group may submit combined or consolidated audited or reviewed financial statements.
o Where the Group or the Group’s parent submit a combined or consolidated statement, supplemental consolidated or combined schedules covering each professional employer organization registered under the group must be included.
o If a bond or security is to be submitted in place of financial statements, email or call us for submission information.
•Attach proof of New York Workers’ Compensation and Disability Insurance:
oIf you have office and internal employees in New York, provide evidence of coverage for New York State Workers’ Compensation and
Disability Insurance by attaching copies of Form
oIf you have no office or internal employees in New York, attach Form
•If a corporation, the request must be signed by an officer of the corporation authorized to bind the entity.
•If a partnership, proprietorship or LLC, the request must be signed by a partner, owner or member authorized to bind the entity.
•Mail the completed request with all attachments to:
New York State Department of Labor
Division of Labor Standards
Permit and Certificate Unit
State Office Campus
Building 12, Room 185B
Albany, NY 12240
F. Responsibilities (applicable to individual and group applicants)
•Within 60 days of the end of each calendar quarter, the PEO must submit a statement, signed by an independent CPA, certifying that there
is reasonable assurance that the firm has timely paid all applicable federal and state payroll taxes on all New York employees (for example: office, worksite, etc.) for that quarter and explaining the basis for this certification.
•Within 60 days of the end of each calendar quarter, a client list must be submitted, showing all changes since the last list submitted. Include the name and address, FEIN, type of business, and name of New York State Workers’ Compensation and Disability Insurance policyholders for each new client. The list should be signed by an officer, partner, owner or member, certifying the list is complete, current and accurate.
•Upon ending a contract, the client must be advised to contact the Unemployment Insurance (UI) Division concerning its UI liability. Inquiries can be directed to Liability and Determination Section, Unemployment Insurance Division, Department of Labor, State Campus, Albany, NY 12240. The telephone number is (518)
LS 665 (06/20) |
Page 3 of 4 |
G. Declaration (to be completed by individual and group applicants)
By filing this request, the applicant authorizes the Unemployment Insurance Division to release the Unemployment Insurance records of the individual PEO, or PEO parent and each member of the group to the Division of Labor Standards.
I, the undersigned, affirm that I am an officer, partner, proprietor or member of the PEO, or the Applicant and Applicant Group, and am authorized to file this Request for Registration to operate as a PEO, or as a PEO Group, in the State of New York on its behalf or on behalf of the applicant PEO Group. I further affirm that the individual PEO, or PEO parent and each member of the group reviewed and will comply with all legal requirements of statues, in particular Article 31, the New York Professional Employer Act, and regulations of the Department of Labor. I affirm that the information in this request and all attachments is complete and accurate to the best of my knowledge.
Date |
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Signature of Chief Executive Officer, Partner, |
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Sole Proprietor or Member |
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Print name of above signatory |
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H. Group Guaranty (to be completed by each member of a PEO Group)
Each PEO that is a member of the PEO Group and is listed on this request must provide the following guaranty.
Guaranty
I, the undersigned, affirm that I am authorized to file this guaranty with the Department of Labor of the State of New York on
behalf of |
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[insert PEO name] (hereinafter Member Company). |
Member Company is a PEO member of the |
[insert name of applicant] |
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PEO Group and joins in the application for registration as a PEO group.
As part of this request, Member Company guarantees payment of all legal financial obligations of all other PEOs listed as members of the PEO Group in the request so long as they continue as members of the Group and under the common ownership and control of the applicant.
Date Signed |
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Signature of Chief Executive Officer, Partner, |
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Sole Proprietor or Member |
Print name of above signatory
LS 665 (06/20) |
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Form Information
| Fact Name | Fact Details |
|---|---|
| Purpose | The New York LS 665 form is used for registering Professional Employer Organizations (PEOs) in New York State. |
| Governing Law | This form is governed by Article 31 of the New York Labor Law. |
| Submission Deadline | Initial applications must be submitted before operating in New York. Renewals are due within 180 days after the fiscal year ends. |
| Contact Information | For inquiries, applicants can email [email protected] or call (518) 457-1942. |
| Ownership Disclosure | Applicants must disclose individuals or entities owning 5% or more of the PEO or parent organization. |
| Financial Requirements | A reviewed or audited financial statement showing a minimum net worth of $75,000 is required. |
| Client List | Applicants must provide a confidential list of all New York clients, including their details. |
| Insurance Proof | Proof of New York Workers’ Compensation and Disability Insurance must be attached with the application. |
| Signature Requirement | The application must be signed by an authorized officer, partner, or member of the entity submitting the request. |
Detailed Guide for Filling Out New York Ls 665
Completing the New York LS 665 form requires careful attention to detail. Ensure all required information is accurate and complete before submission. After filling out the form, it must be mailed to the appropriate address along with any necessary attachments.
- Indicate the type of request by checking the appropriate box: Initial or Renewal for an individual PEO or a PEO Group.
- Provide general information:
- Enter the name of the individual PEO or parent organization.
- List any additional names under which the PEO conducts business.
- Select the type of business organization.
- Input the Federal Employer Identification Number (FEIN).
- Fill in the complete physical address of the Principal Administrative Office.
- Provide a mailing address if different from the physical address.
- List the telephone, fax, and email address of the Principal Administrative Office.
- List current addresses of additional offices in New York.
- List addresses of offices maintained in New York during the past five years.
- Indicate the start and end dates of the fiscal year.
- Complete the ownership information:
- List all persons or entities owning 5% or greater interest in the PEO or parent organization.
- List all persons or entities that have owned 5% or greater interest in the past five years.
- If applicable, list all persons or entities owning 50% or greater interest if the company is publicly traded.
- If applying as a group, provide group information:
- List all Professional Employer Organizations in the group, including their FEIN and addresses.
- List any additional names used by the PEOs.
- List addresses of additional offices maintained by each member of the group in New York.
- List addresses of offices maintained in New York by each member during the past five years.
- Follow submission instructions:
- Email [email protected] or call (518) 457-1942 for questions.
- Mark whether the request is initial or renewal on the first page.
- Attach required documents, including corporate filing receipts and client contracts.
- Attach a list of all New York clients and financial statements prepared by a CPA.
- Provide proof of Workers’ Compensation and Disability Insurance.
- Sign the form according to the entity type (corporation, partnership, etc.).
- Mail the completed form and all attachments to the specified address:
- New York State Department of Labor
- Division of Labor Standards Permit and Certificate Unit
- State Office Campus Building 12, Room 185B
- Albany, NY 12240
Obtain Answers on New York Ls 665
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What is the purpose of the New York LS 665 form?
The New York LS 665 form is used for the registration of Professional Employer Organizations (PEOs) in New York State. This includes initial registrations and renewals for individual PEOs and PEO groups. The form collects essential information about the organization, its ownership, and its operations within the state.
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Who needs to complete the LS 665 form?
Both individual PEOs and groups of PEOs must complete the LS 665 form. Individual applicants should fill out the form for their specific organization, while group applicants need to provide additional information about all PEOs within the group. This ensures that all entities are properly registered and compliant with state regulations.
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What information is required on the LS 665 form?
The form requires various details, including:
- Name and ownership structure of the PEO or parent organization.
- Federal Employer Identification Number (FEIN).
- Addresses of the principal office and any additional offices in New York.
- Ownership information, including individuals or entities with significant ownership stakes.
- Financial statements prepared by a certified public accountant.
- Proof of Workers’ Compensation and Disability Insurance.
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How do I submit the LS 665 form?
Once the LS 665 form is completed, it must be mailed to the New York State Department of Labor at the specified address. Ensure that all required attachments are included, such as financial statements and proof of insurance. For any questions, you can reach out via email or phone as provided on the form.
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What are the deadlines for submitting the LS 665 form?
For initial registrations, the LS 665 form must be submitted before operating as a PEO in New York. If renewing, the application should be submitted no later than 180 days after the end of the PEO's fiscal year. Timely submission is crucial to maintain compliance and avoid penalties.
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What are the responsibilities of a registered PEO?
Once registered, a PEO has several ongoing responsibilities, including:
- Submitting quarterly statements signed by an independent CPA, certifying timely payment of payroll taxes.
- Providing updated client lists that reflect any changes since the last submission.
- Advising clients about their Unemployment Insurance liabilities upon contract termination.
These responsibilities help ensure compliance with state laws and regulations.
Common mistakes
Filling out the New York LS 665 form can be a straightforward process, but several common mistakes can lead to delays or rejections. One frequent error is failing to check the appropriate box for the type of request. Applicants must specify whether the request is for an initial registration or a renewal, and whether it is for an individual PEO or a PEO group. Neglecting to do this can cause confusion and may result in the application being returned for correction.
Another mistake involves incomplete or incorrect ownership information. The form requires detailed information about individuals or entities that own a five percent or greater interest in the PEO. Applicants sometimes overlook this requirement or fail to provide accurate addresses for these owners. This omission can lead to further inquiries from the Department of Labor, delaying the registration process.
Additionally, many applicants forget to include necessary attachments. For instance, the form requires proof of New York Workers’ Compensation and Disability Insurance. Without the appropriate documentation, such as Form C-105.2 or DB-120.1, the application may be deemed incomplete. It's crucial to double-check that all required documents are included before submission.
Lastly, some individuals fail to ensure that the form is signed by an authorized person. Whether it is a corporate officer, partner, or member, the signature must come from someone with the authority to bind the organization. An unsigned application or one signed by an unauthorized individual will not be processed. Attention to these details is essential for a smooth application experience.
Documents used along the form
The New York LS 665 form is essential for Professional Employer Organizations (PEOs) seeking registration in New York State. Along with this form, several other documents are commonly required to ensure compliance with state regulations. Below is a list of these documents, each accompanied by a brief description.
- Client Contract: This document outlines the agreement between the PEO and its clients, detailing the services provided and the responsibilities of each party. It must include specific provisions mandated by New York Labor Law.
- Financial Statement: A reviewed or audited financial statement must be submitted, prepared by a certified public accountant. This statement demonstrates the PEO's financial health and confirms it meets the minimum net worth requirement.
- Proof of Workers' Compensation and Disability Insurance: Evidence of coverage for New York State Workers' Compensation and Disability Insurance is required. This may include certificates from insurance carriers or exemption forms if applicable.
- Client List: A comprehensive list of all New York clients must be provided. This list includes details such as the client's name, address, and federal employer identification number (FEIN), and is kept confidential.
These documents work together with the LS 665 form to create a complete application for PEO registration. Ensuring all required materials are submitted can help streamline the registration process and maintain compliance with New York State regulations.
Similar forms
- New York LS 664 Form: Similar to the LS 665, this form is also used for registering Professional Employer Organizations (PEOs) in New York. It requires basic information about the organization, ownership details, and proof of compliance with state regulations.
- New York LS 663 Form: This form is for the application of a PEO to obtain a Certificate of Authority. Like the LS 665, it involves submitting ownership information and proof of financial stability.
- New York LS 661 Form: Used for reporting changes in the business structure of a PEO, this form requires similar details regarding ownership and business operations, ensuring compliance with state laws.
- New York LS 660 Form: This form is for annual reporting of financial statements by PEOs. It shares the need for financial disclosures and certifications from certified public accountants, much like the LS 665.
- New York DB-120.1 Form: This certificate is required for proving compliance with New York's Disability Insurance requirements. It complements the LS 665 by ensuring that PEOs maintain necessary insurance coverage.
- New York C-105.2 Form: Similar to the DB-120.1, this form serves to demonstrate compliance with Workers' Compensation Insurance requirements. It is often submitted alongside the LS 665 to show insurance coverage.
- New York CE-200 Form: This form is used to claim exemption from Workers' Compensation and Disability Insurance. It is relevant for PEOs that do not have internal employees, similar to the LS 665 in its focus on compliance.
- IRS Form 941: This form is used for reporting payroll taxes to the federal government. Like the LS 665, it requires accurate reporting of employee data and tax payments, ensuring compliance with tax obligations.
Dos and Don'ts
When filling out the New York LS 665 form, attention to detail is crucial. Here’s a list of things you should and shouldn't do to ensure your application is processed smoothly.
- Do check the type of request you are submitting—initial or renewal—before completing the form.
- Do provide accurate and complete information for all required fields, including the Federal Employer Identification Number (FEIN).
- Do attach all necessary documentation, such as proof of insurance and financial statements, as specified in the submission instructions.
- Do ensure that the application is signed by an authorized individual, such as a CEO or partner, to validate the submission.
- Do keep copies of all submitted documents for your records.
- Don't leave any fields blank; incomplete forms may lead to delays or rejections.
- Don't submit the application without reviewing it for accuracy, as errors can cause significant setbacks.
- Don't forget to submit your application within the required time frame to avoid penalties or operational delays.
- Don't ignore the requirement for confidentiality regarding client information; ensure that sensitive details are handled appropriately.
- Don't hesitate to reach out for assistance if you have questions about the form or submission process.
Misconceptions
Misconceptions about the New York LS 665 form can lead to confusion and potential issues for Professional Employer Organizations (PEOs). Here are six common misconceptions and clarifications regarding the form:
- Misconception 1: The LS 665 form is only for new PEOs.
- Misconception 2: Only the primary applicant needs to provide ownership information.
- Misconception 3: The financial statement requirement can be ignored if the PEO is small.
- Misconception 4: The LS 665 form does not require proof of insurance.
- Misconception 5: Submitting the form late will not have consequences.
- Misconception 6: A single signature from any employee is sufficient for the form.
This form is required for both initial registrations and renewals. Existing PEOs must submit renewal applications within a specified timeframe.
All entities with a five percent or greater ownership interest must be disclosed, including those who have held interest in the past five years. This ensures transparency in ownership.
All PEOs must submit a reviewed or audited financial statement prepared by a certified public accountant, regardless of size. This is essential for compliance.
Proof of New York Workers’ Compensation and Disability Insurance is mandatory. This protects both employees and the PEO from legal liabilities.
Late submissions can result in penalties or loss of registration. Timely submission is crucial to maintain compliance with New York State regulations.
The form must be signed by an authorized officer, partner, or member of the PEO. This ensures that the individual filing has the authority to bind the organization.
Key takeaways
The New York Ls 665 form is essential for Professional Employer Organizations (PEOs) seeking registration in New York State. It is necessary to determine whether the application is for an initial registration or a renewal.
Accurate completion of the form is crucial. Applicants must provide detailed information about their business structure, ownership, and any additional offices maintained in New York.
Supporting documents are required with the application. These include a corporate filing receipt, proof of insurance, and a financial statement prepared by an independent CPA.
Timely submission is important. Initial applications must be submitted before starting operations, while renewal applications are due within 180 days after the end of the fiscal year.
Ongoing responsibilities include submitting quarterly statements and client lists to ensure compliance with state regulations regarding payroll taxes and client information.