ࡱ>      @ Fbjbj )^tbbbb>H>H>H8vHI3jKvN(OOORT\V$RqX$L]Q^RL]L]$bbOOeeeL]bOOeL]een.6JO^K \r>H_6 d03Vɘbɘ@J2d@bbbbɘJPV|XDeYZVVV$$$+3De3 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PROFESSIONAL EMPLOYER ORGANIZATIONS S.C. Code Ann. 40-68-10 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov (803) 734-4200 PROFESSIONAL EMPLOYER ORGANIZATION QUARTERLY REPORT FORM In order to be in compliance with the net worth requirements of South Carolina Code Section 406840 (E), Regulation 28-1000(G) requires all licensed professional employer organizations and professional employer organization groups to file a quarterly financial attestation with the department. This quarterly attestation report must be executed by the chief financial officer, the chief executive officer, and a controlling person of the professional employer organization. Copies of the current quarters balance sheet and income statement also must be submitted with the quarterly financial attestation report. Quarterly financial statements are due to be submitted to the department within 75 days after the end of each quarter. Quarterly financial reports that are submitted late without prior approval from the department will be assessed a late reporting fee of one hundred fifty dollars for every thirty days or portion thereof they are late. If they are late more than sixty days, the licensee may be subject to a disciplinary action as set forth in Section 40-68-160 (C). The following attestations must be made in the quarterly report: (1) Health insurance, life insurance, workers compensation insurance and their respective premiums and any other employee benefits have been paid to the proper payees; (2) Working capital is sufficient to meet the licensees ongoing obligations; and (3) Federal, state, and local payroll taxes have been paid as required by regulations of each taxing authority. To complete the Form, the chief executive officer must read, sign and date the CEO Statement. The chief financial officer must attach copies of the current quarters balance sheet and income statement, and sign and date the CFO Statement. The controlling person must sign and date the Controlling Person Statement. In addition, a copy of a workers compensation certificate clearly indicating that the licensed PEO or PEO Group has a workers compensation insurance policy in effect for the current quarter must be attached. A new copy of the certificate is required for each quarter that a report is filed. The certificate must show the South Carolina Department of Consumer Affairs as a certificate holder. RESTRICTED LICENSE HOLDERS ONLY: For companies with a restricted license issued pursuant to South Carolina Code Section 40-68-90, a Controlling Person must complete the Restricted License Affidavit of Employee Count. INFORMATION UPDATE: Since the date you filed your last application or quarterly report, have there been any changes in your companys name, your companys address, your companys structure or ownership, your controlling persons, your primary or secondary contact persons, your personnel subject to continuing education requirements, or your list of client companies?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the answer is yes to any of these items, please attach a sheet showing updated information. Name of PEO or PEO Group: FORMTEXT      SC License #: FORMTEXT      Federal ID #: FORMTEXT      State ID #(withholding): FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone: FORMTEXT      Fax: FORMTEXT      Web site: FORMTEXT       Report for the Quarter Ending:  FORMCHECKBOX  March 31  FORMCHECKBOX  June 30  FORMCHECKBOX  September 30  FORMCHECKBOX  December 31 Year: FORMTEXT      Total Gross South Carolina Payroll For This Quarter: $  Name of Chief Executive Officer: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Name of Chief Financial Officer: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Name of Controlling Person: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       The completed Quarterly Report Form should be submitted to: South Carolina Department of Consumer Affairs Attn: PEO Licensing and Regulation P.O. Box 5757 Columbia, SC 29250-5757 Do not fax this form. An original, signed and notarized form is required.  CEO STATEMENT As the Chief Executive Officer of the licensee filing this Quarterly Report Form, I certify that all premiums for health insurance, life insurance, workers compensation insurance, and any other benefits accruing to our leased employees or their dependents have been and or currently being paid in a timely manner to the proper payees as required by contract, law, or other obligatory documents. I certify that I understand that South Carolina law requires a PEO or PEO Group to maintain working capital sufficient to meet the licensees ongoing obligations and a net worth of $50,000 (or positive net worth for PEOs operating on or before January 1, 1991). I further certify that this licensee is in compliance with those requirements. I certify that I understand that this periodic certification is incomplete unless all required information is attached to this form. I swear or affirm and certify that I have completed and/or reviewed all information submitted on and with this form, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact. I further certify that I understand that giving false information constitutes cause for disciplinary action and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.  Signature FORMTEXT      Date FORMTEXT      Type or Print Your Name and Title  SWORN TO AND SUBSCRIBED before me this ________ day of _____________________, 20______ ________________________________________________ (SEAL) Notary Public For __________________________________ My Commission Expires: _____________________________ CFO STATEMEnt As the Chief Financial Officer of the licensee filing this Quarterly Report Form, I certify that all Federal, State, and local payroll taxes (including unemployment compensation) have been paid as required by the laws and/or regulations of each applicable taxing authority. I further certify that all premiums for health insurance, life insurance, workers compensation insurance, and any other benefits accruing to our leased employees or their dependents have been and or currently being paid in a timely manner to the proper payees as required by contract, law, or other obligatory documents. I certify that I understand that South Carolina law requires a PEO or PEO Group to maintain working capital sufficient to meet the licensees ongoing obligations and a net worth of $50,000 (or positive net worth for PEOs operating on or before January 1, 1991). I further certify that this licensee is in compliance with those requirements. I certify that I understand that this periodic certification is incomplete unless all required information is attached to this form. I have attached copies of the current quarters balance sheet and income statement. I swear or affirm and certify that I have completed and/or reviewed all information submitted on and with this form, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact. I further certify that I understand that giving false information constitutes cause for disciplinary action and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.   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I further certify that I understand that giving false information constitutes cause for disciplinary action and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.  Signature FORMTEXT      Date FORMTEXT      Type or Print Your Name and Title  SWORN TO AND SUBSCRIBED before me this ________ day of _____________________, 20______ ________________________________________________ (SEAL) Notary Public For __________________________________ My Commission Expires: _____________________________ RESTRICTED LICENSE Affidavit of EMPLOYEE cOUnt I swear or affirm that at no time during the quarter that is the subject of this report did the Licensee employ more than forty (40) leased employees in the State of South Carolina. I further certify that I understand that giving false information constitutes cause for disciplinary action and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.  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