Form Dws-Ark-209br - Employer'S Quarterly Contribution And Wage Report
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2NAICS
AUD
CO
EMPLOYER’S QUARTERLY CONTRIBUTION AND WAGE REPORT
ARKANSAS DEPARTMENT OF WORKFORCE SERVICES
P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3798
REIMBURSABLE
DWS ID NUMBER
DATE QUARTER ENDED
FEDERAL ID NUMBER
REPORT DUE DATE
Check box and return if no wages paid c
PART A.
1st mo
2nd mo
3rd mo
1. Number of employees in the pay period including the 12th of:
of qtr _________ of qtr _________ of qtr _______
2. Total of all wages paid for personal services, including bonuses/commissions ............... $ _ ______________.____
3. Penalty (see instructions) ..................................................................................................... $________________.____
4. Amount of remittance (make payable to Arkansas Department of Workforce Services) ........ $________________.____
CASHIER’S STAMP
DO NOT ALTER THIS FORM
Initial
PART B.
Amt received
Enter the SSN, first name, middle initial, last name and
total wages paid to each employee during the calendar
quarter in the space provided below (continuation sheet
Penalty code
provided).
SOCIAL SECURITY NUMBER
FIRST NAME, MIDDLE INITIAL & LAST NAME OF EMPLOYEE
TOTAL WAGES PAID
1 )
$
.
2 )
$
.
3 )
$
.
4 )
$
.
5 )
$
.
6 )
$
.
7 )
$
.
8 )
$
.
9 )
$
.
10 )
$
.
11 )
$
.
12 )
$
.
PAGE ONE OF _______ PAGE(S)
$
.
TOTAL NO. OF EMPLOYEES
TOTAL WAGES FOR THIS PAGE
ON THIS REPORT __________
I HEREBY CERTIFY THIS REPORT IS TRUE AND CORRECT.
SIGNATURE ______________________________TITLE __________________________ DATE _______________ TELEPHONE __________________
DWS-ARK-209BR
(REV. 06-06)
MAINTAIN COPY FOR YOUR RECORDS
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