Form Uia 1028 - Employer'S Quarterly Wage/tax Report Page 2
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2SECTION 2 (continued)
[
]
Family
Gross Wages Paid
Delete
Owned
M.
Social Security No.
Employee Last Name
Employee First Name
“X”
This Quarter
Enter
“F”
If you have more than 25 employees and/or out-of- state
wages, You must use MiWAM to file on-line.
Total Gross Wages paid this quarter:
SECTION 3
Excess
Wages:
Taxable Wages:
UI Tax Rate (ABC +CBC + NBC): x
UI Tax Due (UI Tax Rate x Taxable Wages) Round to Nearest $:
Obligation Assessment (OA) Rate: x
OA Due (OA Rate x Taxable Wages) Do Not Round:
Total Amount Due (UI Tax Due + OA Due):
Prior Balance:
Check this box if this is the Final Report for this business.
Amount Enclosed:
(Prepare and submit form UIA 1772)
Taxable Wage Limit
DUE DATE:
SECTION 4
YOUR CERTIFICATION: I certify that I have examined this report, and that to the best of my knowledge and belief
it is correct and complete.
_____________________________________________________________________________________________
Signature
Title
Date
Contact Phone Number
For questions, call the Office of Employer Ombudsman (OEO) at 1-855-4UIAOEO(855-484-2636). Outside of
Michigan, please call 1-313-456-2300. Questions may also be emailed to OEO@michigan.gov.
MAKE A COPY OF THIS REPORT FOR YOUR RECORDS.
LARA is an Equal Opportunity Employer/Program.
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