Form 65-5300 - Employer'S Contribution & Payroll Report - 2012

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UI Account #
Filing Quarter
Filing Year
Employer's Contribution & Payroll Report
65-5300 (08-12)
If you need more wage lines or have additional reporting units, copy this page.
Reporting Unit Number:
Total Wages for this reporting unit: $
Worksite Address 1:
Worksite Address 2:
City:
State/Province:
Zip/Postal Code:
Wage Information
Enter the wage information for each employee of this Reporting Unit. To get credit for taxable wages paid in another state, you must file
this report online at
Social Security Number
Employee Name (Last, First, MI)
Total Wages Paid
Taxable Wages Paid
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Totals For This Page:
Labor Market Information for this Reporting Unit
If you have any questions about Labor Market Information, call (800) 532-1249 or fax (515) 281-8195.
1. Enter the number of employees (workers) who worked during or
1st Month:
2nd Month:
3rd Month:
received pay for the pay period that includes the 12th of the month:
2. Enter amount of pay which exceeds regular and recurring payments
$
to employees such as bonus, executive pay, severance pay, etc:
3. If the number of workers increased or decreased
1. Seasonal Change
3. Layoff
5. Worksite Opening
during the quarter for any of the following reasons,
2. Labor Dispute
4. Recall
6. Worksite Closing
check the box(es) to indicate the reason(s).
Page __ of ___
Administrative Use Only
FD:
LD:
Batch #:
Delinquent After Date:

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