Form C-147 - Employer'S Quarterly Wage & Contribution Report

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Vermont Department of Labor

EMPLOYER'S QUARTERLY WAGE

Attn: Employer Services

& CONTRIBUTION REPORT

P.O. Box 488

Montpelier, Vermont 05601-0488

TO ENSURE PROPER CREDIT TO YOUR ACCOUNT,

DEPARTMENT COPY MUST BE RETURNED WITH PAYMENT.

FOR INSTRUCTIONS, SEE PAGE 2 AND 3.

INDICATE THE NAME AND ADDRESS OF YOUR BUSINESS

Department

BELOW. PLEASE CHECK THIS BOX IF THIS IS A NEW

EMPLOYER NUMBER

MAILING ADDRESS.

Copy

EMPLOYER NAME

PLEASE

Q-YR

DO NOT

QUARTER ENDING

SEND

DUE DATE

PHOTOCOPY

EMPLOYEE WAGE DATA FOR THIS QUARTER (Please type or print entries IN BLACK or BLUE INK only.)

1. SOCIAL SECURITY

3. TOTAL GROSS WAGES

5. HOURLY

6. GENDER

2. EMPLOYEE'S NAME (Last, First, Middle Initial)

4. H/S

NUMBER

RATE

M - F

PAID THIS QUARTER

TOTAL WAGES

C-101 WEB (9/05)

7. PAGE 1 of

PAGE

THIS PAGE

8. For each month, report the number of covered

2ND MONTH TOTAL

1ST MONTH TOTAL

3RD MONTH TOTAL 3RD MONTH FEMALE ONLY

workers who worked during or received pay for the

C-101 WEB (9/05)

payroll period which includes the 12th of the month.

Department Use Only

EMPLOYER NUMBER

9. Total Gross Wages Paid to all Subject Employees This Quarter

10. Portion of Quarterly Wages from item 9 IN EXCESS of

EMPLOYER NAME

Calendar Year Limit per Employee of

Q-YR

11. Taxable Wages - Subtract item 10 from item 9

12. Contribution Tax Due

QUARTER ENDING

(item 11) Times Your Rate of

13. Credit Adjustment (Subject to change - See Instructions)

DUE DATE

14. TOTAL (Line 12 minus Line 13) If amount is negative, enter 0.

Payable to: VERMONT DEPARTMENT OF LABOR

16. DATE

17. TELEPHONE

DEPARTMENT USE ONLY

15.

No longer have employees in Vermont

Discontinued business in Vermont

18. SIGNATURE & TITLE (Must be owner, principal officer or authorized representative)

Ownership or name as shown has changed

I certify that I have complied with the requirements of 21 V.S.A. Section 687 relating to securing workers' compensation coverage for my employees and the information

contained in this report and all attachments is correct to the best of my knowledge.