Form De 3086m Waiver Request From Filing Quarterly Wage Reports On Magnetic Media
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1WAIVER REQUEST
FROM FILING QUARTERLY WAGE REPORT(S) ON MAGNETIC MEDIA
PART I - EMPLOYER INFORMATION
Employer Name:
Date:
Mailing Address:
State ID Number:
City/State/ZIP:
Federal ID Number:
Contact Name:
Title:
Telephone Number:
(
)
PART II - WAIVER REQUEST INFORMATION
1.
This request is for TAX YEAR ____________ QUARTER(S) ____________
2.
Is this the first year you have submitted a waiver request?
YES
NO
3.
Do you presently own a computer?
YES
NO
4.
Briefly explain your need for a waiver:
The waiver request must be filed within 90 days of becoming subject to the magnetic media requirement.
Approved requests are valid for up to a maximum of one year. Subsequent requests for a waiver must be filed
separately on form DE 3086M. If this waiver is approved, the paper Quarterly Wage and Withholding
Report, DE 6, must be filed by the report due date. Questions may be directed to (916) 654-6845. Waiver
request should be faxed to (916) 654-0302 or mailed to:
Employment Development Department
Electronic Filing Group, MIC 15
Mag Media Unit
P.O. Box 826880
Sacramento, CA 94280-0001
PART III - SIGNATURE
Under penalties of perjury, I declare that I have examined this form, including any accompanying statements, and, to
the best of my knowledge and belief, it is true, correct and complete.
Signature:
Title:
Date:
DE 3086M Rev. 1 (5-03) (INTERNET)
Page 1 of 1
CU
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