Form Uia 1028 - Employer'S Quarterly Wage/tax Report
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UIA 1028
State of Michigan
Authorized by
(Rev. 02-13)
Department of Licensing and Regulatory Affairs
MCL 421.1 et seq.
Unemployment Insurance Agency
3024 W Grand Blvd, Suite 11-500, Detroit, MI 48202
Shaun Thomas
Rick Snyder
Acting Director
GOVERNOR
Employer’s Quarterly Wage/Tax Report
Mail To:
Unemployment Insurance Agency
Tax Office
PO Box 33598
Detroit, MI 48232-5598
YOU MUST FILE THIS REPORT EVEN IF YOU ARE UNABLE TO PAY OR HAVE NO PAYROLL FOR THE QUARTER.
For details about completing this report see the instructions page.
Employer Type: Contributing
(Complete Sections 1, 2, 3 & 4)
Reimbursing
(Complete Sections 1, 2 & 4)
SECTION 1
Check this box if this is an Amended report. Explain:________________________________________________
_____________________________________________________________________________________________
Provide the number of all full-time employees
plus part-time employees who worked during
or received pay for the pay period that includes
UIA Employer Account No: ______________________________
th
the 12
of the month:
FEIN: _______________________________________________
st
nd
rd
1
Month
2
Month
3
Month
Quarter Ending Date (mm/dd/yyyy):________________________
SECTION 2
List only employees who had wages during this quarter
Family
Gross Wages Paid
Delete
Owned
.
Social Security No.
Employee Last Name
Employee First Name
Enter
“X”
This Quarter
“F”
If more lines are needed to enter employee information, continue
to Section 2 on back of form. When finished entering employees,
continue to Section 3 for Contributing Employers or Section 4 for
Reimbursing Employers.
_____________________________________________________________________________________________
For UIA Use Only. Do Not Write Below Line.
(Barcode) 99991206456123
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