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Form C-147 Employer'S Quarterly Wage & Contribution Report - Vermont Department Of Labor

EMPLOYER'S QUARTERLY WAGE

VERMONT DEPARTMENT OF LABOR

& CONTRIBUTION REPORT

Attn: Employer Services

P.O. Box 488

TO ENSURE PROPER CREDIT TO YOUR ACCOUNT,

Montpelier, VT 05601-0488

DEPARTMENT COPY MUST BE RETURNED WITH PAYMENT.

FOR INSTRUCTIONS, SEE PAGE 2 AND 3.

EMPLOYER NUMBER

Department

INDICATE THE NAME AND ADDRESS OF YOUR BUSINESS BELOW.

PLEASE CHECK THIS BOX IF THIS IS A NEW MAILING ADDRESS.

Copy

EMPLOYER NAME

Q-YR

PLEASE

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.)

3. TOTAL GROSS WAGES

1. SOCIAL SECURITY

5. HOURLY

6. GENDER

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

4. H/S

PAID THIS QUARTER

NUMBER

RATE

M - F

TOTAL WAGES

C-101 (2/08)

7. PAGE 1 of

PAGE

THIS PAGE

IF NO ENTRY REQUIRED, ENTER ZEROES.

EMPLOYER NUMBER:

QUARTER ENDING:

DUE DATE:

3rd month FEMALE only

1st Month Total

2nd Month Total

3rd Month Total

EMPLOYMENT INFORMATION

8. For each month during this quarter, report the number of covered employees who

worked or received pay for the payroll period that includes the 12th day of the month.

9. Status of Business - check all that apply

No longer have employees in VT

Discontinued business in VT

Ownership or name as shown above has changed

UI Tax Contributions

Health Care Contributions

16. Adjusted Uncovered FTE:

10. Total Gross Wages Paid to all Subject Employees This Qtr.

(Line C from Worksheet)

17. Total HC Contributions Due:

11. Portion of Quarterly Wages from Line 10 IN EXCESS of

(Line D from Worksheet)

Year Limit Per Employee

Total Amounts Due Vermont Department of Labor (VDOL)

12. Taxable Wages - Subtract Line 11 from Line 10

13. Contribution Tax Due

18. Add Lines 15 and 17 together

(Line 12) Times Your Rate of

and enter total:

Submit payment payable to VDOL for the

14. Credit Adjustment (Subject to Change, see instructions)

total amount indicated on Line 18.

15. TOTAL SUTA Tax Due - Line 13 Minus Line 14;

SIGNATURE AND TITLE

if amount is negative, enter 0

(Must be owner, principal officer or authorized representative)

CERTIFICATION: I certify I have compiled this report with the requirements

Department Use Only

of 21 VSA Section 687 relating to securing workers' compensation coverage

Telephone Number

Date

for my employees and the information contained in this report and all

attachments are correct to the best of my knowledge.

Form C-147 Employer'S Quarterly Wage & Contribution Report - Vermont Department Of Labor

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