Form Ui -11w - Wage Report - 2011
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1YR
QTR
STATE OF NEBRASKA
DEPARTMENT OF LABOR
UNEMPLOYMENT INSURANCE
P O BOX 94600
LINCOLN, NEBRASKA 68509-4600
Employer Account No.
PHONE 402.471.9898
FAX 402.471.9994
Federal I.D. No.
WAGE REPORT UI -11W
File electronically at uiconnect.ne.gov
Report gross quarterly wages paid to each employee. INCLUDE 401K plan.
DO NOT include Section 125 cafeteria plan. Total of all pages reported
must equal Line 2 Gross Wages on Combined Tax Report.
of
Page
THIS DOCUMENT MUST BE FILED WITH THE COMBINED TAX REPORT UI -11T
Social Security
Gross wages paid each covered
Employee’s Name
Number
employee in this quarter
000
00
0000
Last Name, 1st Initial, 2nd Initial
Dollars
Cents
TOTAL OF THIS PAGE
TOTAL OF ALL PAGES
Print Preparer’s Name
Phone Number
Date
UI-11W Revised 3-30-2011
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