Form 501q - Employer'S Quarterly Return

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County of Washington
EHPI-OYER'S OI'ARTERLV RETJRN
form 501Q
1. Total
2. Amount on line 1 subiect to
3. Washinoton Llcense Fee
6. TotalAmountDue of lines 3. 4 and
7. Total Number of
Accunt Number
Interesl
L
5.
to
License Fee this
true, conect and complete return for the quafter ending
I declare this is a
Company Name
SiEature
Date
Title
INSIRUCTIONS FOR COUPLETING YOUR RETURT{
The trtum b lo. a pslod ol t||!G cddrk non[|! rding fHr 31, ,hnc 30, Seliemi€r 30 or Decsdca 31,
md h dlc on or tclo|tlh.lrd &r of th. ||n h Hldhg tlE s|d d lhc qtg.
Llne 1i Enter lolal coflF€nsdhn paid dudng he quad€r, r€gadl€6s vih€n or wherc esmed.
Line2:Entertheamoun|indudedinUne1wltid|rprsenbpqym€nb$ti€db$ev|hdlingbnco.ticeNeFee.1heemphpInustmahbinad€qlstBcoId8b$s6
Lin€ 5: hb|E8l accflr€E on unDail lbans€ fs€s at a rals ol 1296 oer annun lrcrn $s duo dsto of lt€ |dln unlil oail.
llake cftrrf<s payaF and nall wtilr thie card to:
Washington Occupational
License Administrator
(WCOTA), P.0. Box 228, Spdngfield, KY 40069 . (859) 336-5430
More detailed information for employers nn also be obtained fron ttis oflice.

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