Form Mag-1 - Transmitter Report - Magnetic Media Reporting Of W-2 Information To Ctcb Page 2

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Instructions: Complete the following information for each employer, in lieu of item numbers 1,
2, and 7 on front, if multiple employers are being reported on a single magnetic media file.
1. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees
2. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees
3. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees
4. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees
5. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees
6. Name & Mailing Address of Employer:
Federal EIN No.
CTCB Employer No. (if different) No. of Employees

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