Form Uc30h1.frm - Employer'S Annual Contribution And Wage Report - District Of Columbia
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1Department of Employment Services
Government of The District of Columbia
Office of Unemployment Compensation
P.O. Box 96664
Washington, D.C.
20090-6664
Telephone:
Local: (202 ) 698-7550
Toll Free: (877) 319-7346
FORM ID:
EMPLOYER'S ANNUAL CONTRIBUTION
POSTMARK DATE
DOES-UC30H
AND WAGE REPORT
(DO NOT USE THIS SPACE)
FEDERAL IDENTIFICATION NUMBER:
EMPLOYER NUMBER:
NAME CHK:
TAX RATE:
YEAR ENDING:
TAXABLE WAGE BASE:
THIS REPORT DUE:
1. NUMBER OF COVERED WORKERS WHO RECEIVED PAY FOR THE PAY PERIOD WHICH INCLUDES THE 12th OF EACH MONTH
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
2. EMPLOYEE WAGE INFORMATION FOR THIS ANNUAL REPORTING PERIOD..
(PLEASE PRINT OR TYPE)
***********************
W A G E S
*************************************
EMPLOYEE
EMPLOYEE NAME
SOC. SEC. NO.
LAST
FIRST
MI
1st QTR
2nd QTR
3rd QTR
4th QTR
TOTAL
TAXABLE
TO REPORT MORE THAN 10 EMPLOYEES, PLEASE MAKE A COPY OF THIS FORM.
$
3. TOTAL TAXABLE WAGES ..............................................................................................................................................
$
Multiply
4. CONTRIBUTION DUE (
...............................
ITEM 3 by your tax rate of
%)
$
PLUS
Multiply
5.
ADMIN. ASSESSMENT DUE (
......
ITEM 3 by two tenths of one percent (0.2%)
$
6.
PLUS
INTEREST DUE....................................................................................................
$
7.
PLUS
PENALTY DUE.....................................................................................................
$
MINUS
8.
APPROVED CREDIT..........................................................................................
$
9.
EQUALS
TOTAL REMITTANCE AMOUNT
(Make check or money order payable to 'DOES') ................................................
ENTER THE APPROPRIATE INFORMATION IF ANY CHANGE HAS OCCURRED.
10.
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
DESCRIBE ANY OTHER CHANGE:
.
CERTIFICATION
I CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT AND ANY WAGE REPORT(S) ATTACHED HERETO IS
TRUE AND CORRECT AND THAT NO PART OF THE TAX WAS OR IS TO BE DEDUCTED FROM ANY WORKER'S WAGES.
DATE:
TELEPHONE:
SIGNATURE:
PRINT NAME:
TITLE:
UC30H1.FRM rev 03/06
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