Monthly Statement Form

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Business Name
Monthly Statement
UI Tax and Wage Administration
ES Reference No.
PO Box 34949
Seattle, WA 98124-1949
Unified Business Identifier No.
Your District Tax Office Telephone Number
*PLEASE SEE REVERSE SIDE FOR EXPLANATIONS
Transaction Description
Amount
*We will charge you penalties and interest if you do not pay your taxes by the due date.
If you have made changes to your business or account, please complete the reverse side.
Tax Due
EAF
Payment Penalty
Interest
Report Penalty
Legal Fees
Prior Balance
+ New Charges
- Payments
- Credits
= Balance Due
EMS 5229-1 (Rev. 10/07)
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EMS 5229-1 Rev. 10/07)
DETACH HERE
Pay electronically at
OR
Return this portion with your check payable to
Please check if you have provided updated account information on the reverse
Employment Security Department,
PO Box 34949, Seattle, WA 98124-1949.
Please write your ES reference number on your check.
Statement Closing Date
Balance
Payment Due Date*
ES Reference Number
Amount Remitted
For Departmental Use Only
Date
Staff ID
Received

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