10. List in each week the greatest number of employees, PERFORMING SERVICE IN OHIO for remuneration of any kind and provide the total
gross wages paid in each quarter. (Exception: For agricultural employment or domestic employment in a private home, college club, fraternity
or sorority, the gross wage total should include cash wages only and not the cash value of compensation in any other medium.) The current
year should be listed first with prior years listed beneath in descending order. THIS INFORMATION SHOULD RELATE ONLY TO THE
EMPLOYER YOU HAVE LISTED IN QUESTION #1 OF THIS FORM AND NOT THE PREVIOUS EMPLOYER (IF ANY).
WAGES PAID
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
$
$
$
$
WEEK
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
ENTER HERE
1st
CURRENT
THE GREATEST
YEAR
NUMBER OF
2nd
WORKERS ON
20
A DAY IN
3rd
EACH WEEK
4th
5th
WAGES PAID
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
$
$
$
$
WEEK
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
ENTER HERE
1st
YEAR
THE GREATEST
NUMBER OF
2nd
20
WORKERS ON
A DAY IN
3rd
EACH WEEK
4th
5th
WAGES PAID
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
$
$
$
$
WEEK
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
ENTER HERE
THE GREATEST
1st
YEAR
NUMBER OF
WORKERS ON
2nd
20
A DAY IN
EACH WEEK
3rd
4th
5th
WAGES PAID
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
$
$
$
$
WEEK
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
ENTER HERE
1st
THE GREATEST
YEAR
NUMBER OF
2nd
WORKERS ON
20
A DAY IN
3rd
EACH WEEK
4th
5th
11. IF YOU BELIEVE THAT ANY ADDITIONAL INDIVIDUAL(S) PERFORMING SERVICES SHOULD BE EXCLUDED OR SHOULD NOT BE
CONSIDERED YOUR EMPLOYEE FOR UNEMPLOYMENT COMPENSATION PURPOSES, ATTACH A WRITTEN STATEMENT
PROVIDING THE INDIVIDUAL’S NAME, SOCIAL SECURITY NUMBER, AMOUNT OF REMUNERATION PAID AND YOUR REASONS.
(If an exclusion is claimed for a son or daughter, also provide their date of birth.)
12. Person in charge of payroll records and address where payroll records are kept.
(name)
(street)
(city)
(state)
(zip)
(telephone #)
CERTIFICATION: I hereby certify that the information given in this report is true to the best of my knowledge and belief.
(employer signature)
(title)
(date)
INFORMATION FURNISHED ON THIS REPORT WILL BE USED TO DETERMINE LIABILITY FOR CONTRIBUTIONS UNDER THE OHIO
UNEMPLOYMENT COMPENSATION LAW.
Prepared by: (name)
(telephone #)
(date)
PLEASE SEE REVERSE SIDE FOR LAW AND RULES APPLICABLE TO EMPLOYER LIABILITY. IF YOU HAVE
ACQUIRED YOUR BUSINESS BY PURCHASE OR OTHERWISE, YOU MUST ALSO COMPLETE FORM JFS 66302.
JFS 66300 (Rev. 4/2010)
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