Form Nucs-4073 - Emploewr'S Quarterly Contribution And Wage Report - State Of Nevada
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DO NOT STAPLE THIS FORM
State of Nevada
Department of Employment, Training & Rehabilitation
EMPLOYMENT SECURITY DIVISION
500 E. Third St., Carson City, NV 89713-0030
Telephone (775) 684-6300
PLEASE CORRECT ANY NAME OR ADDRESS INFORMATION BELOW.
1b.
FOR QUARTER ENDING
1e.
FEDERAL I.D. NO.
1a. EMPLOYER ACCOUNT NUMBER
1c.
DELINQUENT AFTER
FOR YOUR PROTECTION, VERIFY
YOUR FEDERAL I.D. NO. ABOVE. IF IT
IS IN ERROR, PLEASE ENTER THE
1d.
YOUR RATES
CORRECT NUMBER HERE:
A REPORT MUST BE FILED
Dollars
Cents
3. TOTAL GROSS WAGES (INCLUDING TIPS) PAID THIS QUARTER
INSTRUCTIONS ENCLOSED
(If you paid no wages, write "NONE," sign report and return.)
(See Instructions)
2. REPORT OF CHANGES
If any of the following changes
4. LESS WAGES IN EXCESS OF
PER INDIVIDUAL
have occurred, please check the
(Cannot exceed amount in Item 3.)
(See Instructions)
appropriate box and provide
5. TAXABLE WAGES PAID THIS QUARTER (Item 3 less Item 4.)
details on page 2.
Business Discontinued
6. UI AMOUNT DUE THIS QUARTER (Item 5 x your UI Rate shown in Item 1d.)
Ownership Change
Entire Business Sold
7. CEP AMOUNT DUE THIS QUARTER (Item 5 x the CEP Rate in Item 1d.)
(Add)
Part of Business Sold
(Do not include the CEP amount on federal unemployment tax return Form 940.)
Legal Ownership Change
8. PRIOR CREDIT (Attach "Statement of Employer Account" )
(Subtract)
Business Added
9. CHARGE FOR LATE FILING OF THIS REPORT
(Add)
(FOR DIVISION USE ONLY)
(One or more days late add $5.00 forfeit.)
10. ADDITIONAL CHARGE FOR LATE FILING, AFTER 10 DAYS
(Add)
(Item 5 x 1/10% (.001) for each month or part of month delinquent.)
11. INTEREST ON PAST DUE UI CONTRIBUTIONS
(Add)
(Item 6 x 1% (.01) for each month or part of month delinquent.)
(See Instructions)
12. TOTAL PAYMENT DUE (Total Items 6 through 11.) MAKE PAYABLE TO NEVADA
EMPLOYMENT SECURITY DIVISION.
Please enter Employer Account Number on check.
13. SOCIAL SECURITY
14.
EMPLOYEE NAME
15. TOTAL TIPS
16.
TOTAL GROSS
Do not make adjustments to prior quarters.
NUMBER
REPORTED
WAGES INCLUDING TIPS
Dollars
Cents
Dollars
Cents
17. NUMBER OF WORKERS
LISTED ON THIS REPORT
18. FOR EACH MONTH,
REPORT THE NUMBER OF
WORKERS WHO WORKED
DURING OR RECEIVED
PAY FOR THE PAYROLL
PERIOD WHICH INCLUDES
THE 12TH OF THE MONTH.
1 MO
2 MO
3 MO
19.TOTAL PAGES
20. TOTAL TIPS AND TOTAL
$
$
THIS REPORT
WAGES THIS PAGE
21. I certify that the information contained on this report and the attachments is true and correct.
__________________________________________________________
_______________________________________________________________
Signed/Title
Name of Preparer if Other Than Employer
(______)________________________(______)___________________
(______)__________________________
___________________________
Area Code
Fax Number
Area Code Telephone Number
Area Code
Telephone Number
Date
NUCS-4072 (Rev.9-06)
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