MAGNETIC MEDIA - SUBMITTAL SHEET
QUARTERLY WAGE AND WITHHOLDING INFORMATION
Complete Parts I, II, III, and IV of form. Do not complete a Quarterly Wage and Withholding Report (DE 6) unless
additional quarterly wages are being reported. Questions regarding quarterly reporting may be directed to
(916) 654-6845. Mail completed DE 166 and labeled media to:
Magnetic Media Production Unit, MIC 15
Note: If using land carrier, i.e., UPS or Federal
Employment Development Department
Express, use:
P.O. Box 826204
800 Capitol Mall, MIC 15A
Sacramento, CA 94230-6204
Sacramento, CA 95814
PART I - SUBMITTER / CONTACT INFORMATION
DATE SENT: ___________________
SUBMITTING FIRM NAME AND ADDRESS
PLEASE ENTER REPORTING PERIOD.
DE 6 - QUARTER _________ YEAR _________
NUMBER OF FIRMS REPORTED ON FILE: ________
CHECK IF THIS IS A TEST FILE.
ENTER ADDRESS TO WHICH MEDIA SHOULD BE RETURNED*
NAME, ADDRESS, AND TELEPHONE NUMBER OF PERSON TO
CONTACT FOR TECHNICAL INFORMATION REGARDING FILE.
CHECK FOR CHANGE OF ADDRESS
(
)
EXT:
*NOTE: CD-Rs and diskettes not returned unless requested.
PART II - FIRM(S) BEING REPORTED
(Attach additional sheets if needed. Computer printouts of the required data may also be attached.)
EMPLOYER NAME (FIRM #1)
EMPLOYER NAME (FIRM #2)
EMPLOYER ACCT. NO. BRANCH
FEDERAL ID NUMBER
EMPLOYER ACCT. NO. BRANCH
FEDERAL ID NUMBER
TOTAL SUBJECT WAGES REPORTED ON MEDIA FILE
TOTAL SUBJECT WAGES REPORTED ON MEDIA FILE
$
$
TOTAL PIT WAGES REPORTED ON MEDIA FILE
TOTAL PIT WAGES REPORTED ON MEDIA FILE
$
$
TOTAL PIT WITHHELD ON MEDIA FILE
TOTAL PIT WITHHELD ON MEDIA FILE
$
$
TOTAL NUMBER OF EMPLOYEES REPORTED ON MEDIA FILE
TOTAL NUMBER OF EMPLOYEES REPORTED ON MEDIA FILE
#
#
TOTAL SUBJECT WAGES REPORTED ON PAPER (IF ANY)
TOTAL SUBJECT WAGES REPORTED ON PAPER (IF ANY)
$
$
PART III - MAGNETIC MEDIA FILE INFORMATION
LIST ANY EXTERNAL TAPE CARTRIDGE
CD-R
FILE IDENTIFICATION NUMBERS
3 1/2” DISKETTE
_____________________________________
IBM 3480 TAPE CARTRIDGES
_____________________________________
_____________________________________
IBM 3490 TAPE CARTRIDGES
PART IV - DECLARATION
I declare that the information herein is true and correct to the best of my knowledge and belief.
Signature
Title
Phone (
)
Date
_____________________________
__________________________
_____
________________
_________________
DE 166 Rev. 8 (4-06) (INTERNET)
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