Transcription of INDIANA DEPARTMENT OF WORKFORCE …
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INDIANA DEPARTMENT OF WORKFORCE …
INDIANA DEPT OF WORKFORCE BOX 7054 INDIANAPOLIS IN 46207-7054 AMOUNT DUETOTAL GROSS WAGES PAID THIS QTR (SEE instructions ) (LINE 2 MINUS LINE 3)LINE 4 X APPLIED RATE INTEREST (SEE instructions )PENALTY (SEE instructions ) ((N1 STMO1 STState Form 250 (R9 / 3-11) / Form UC1I CERTIFY, UNDER PENALTY OF PERJURY, THAT THIS REPORT IS TRUE AND COMPLETEELTITSIGNATURE OF EMPLOYER2 NDMO2ND3 RDMO3 RDCONFIDENTIAL RECORD PURSUANT TO IC-22-4-19-6,IC 4-1-6 ICTELEPHONE NUMBER DATEFAX NUMBEREMPLOYEE COUNT (SEE instructions )EMPLOYEECOUNTTOTAL EXCESS WAGES NET TAXABLE WAGES TOTAL PREMIUMS DUE (L((S(NPERIOD COVERED FROM TOACCOUNT NO. Q YR FEDERAL ID NOInstructions for Preparation of Form UC-1 Quarterly Contribution Report s name, address, quarter, applied rate, SUTA account number, and FEIN are inserted by the DEPARTMENT .))))))
indiana dept of workforce development p.o. box 7054 indianapolis in 46207-7054 amount due total gross wages paid this qtr (see instructions) (line 2 minus line 3)
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