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Quarterly Contribution Return and Report of Wages ...

D. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERD. SOCIAL SECURITY NUMBERE. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)E. EMPLOYEE NAME (FIRST NAME)( )( )( )( )( )( )( )(LAST NAME)(LAST NAME)(LAST NAME)(LAST NAME)(LAST NAME)(LAST NAME)(LAST NAME)Check this box if you are reporting ONLY Voluntary Plan Disability Insurance Wages on this Personal Income Tax (PIT) Wages and PIT Withheld, if appropriate.

INSTRUCTIONS FOR COMPLETING THE QUARTERLY CONTRIBUTION RETURN AND REPORT OF WAGES (CONTINUATION), DE 9C PLEASE TYPE ALL INFORMATION You may be required to electronically submit this form.

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