Transcription of Quarterly Contribution and Wage Report
1 MISSOURI DIV. OF EMPLOYMENT SECURITYUNEMPLOYMENT INSURANCE TAX573-751-1995 Quarterly CONTRIBUTIONAND wage REPORTFile online at EMPLOYER NAME AND ADDRESS14. FEDERAL ID NUMBER _____If mailing, return this page with remittance to:Division of Employment Box 888 Jefferson City, MO 65102-0888 Make check payable to Division of Employment Securityor pay online at Report IS DUE BYGREATER OF 10% OR $100 PENALTY AFTERGREATER OF 20% OR $200 PENALTY AFTERP lace X in applicable box and complete Employer Change Request. BusinessEmploymentChange ofSoldCeasedAddress2ndEAU4 MODES-4 (01-19) UITax(Please Print)I certify that the information contained in this Report ,including name and address in Item 1, is true and PREPARER _____ TITLE _____ ProbationarySSNF irstNameMiddleInitialLastNameTotalWagesM ulti-stateCheckIf YesStartDateEndDate21.
2 PAGE OF PAGESTOTAL THIS PAGE2. MO EMPLOYER ACCOUNT (DO NOTUSE)3. CALENDAR QUARTERDate PaidMUST HAVE AMOUNTS IN 4, 5, & 6, EVEN IF ZERO4. TOTAL WAGES PAID5. WAGES PAID IN EXCESS OFPER WORKERPER YEAR (See Instruction Sheet)6. TAXABLE WAGES(Item 4 Minus Item 5)7. TAXES DUE (Multiply Item 6by Your Rate)8. INTEREST ASSESSMENT DUETO FEDERAL ADVANCES9. INTEREST CHARGES OFPER MONTH IFPAID AFTER10. LATE Report PENALTYCHARGES (See Item 15 to the Left)11. OUTSTANDING AMOUNTSAS OF12. TOTAL PAYMENT13. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERSWHO WORKED OR RECEIVED PAY FOR THE PERIOD THAT INCLUDESTHE 12TH OF THE FORM IS READ BY A MACHINE.
3 PLEASE TYPE OR PRINT THIS Division of Employment Security is an equal opportunity employer/program. Auxiliary aidsand servicesare available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 7111st3rd4th
