Form 3h - Employer'S Quarterly Wage List
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1DWS-UI
EmployEr’s QuartErly WagE list
READ REVERSE BEFORE
Form 3H
COMPLETING THIS REPORT
Rev.6/09
utaH DEpartmENt oF WorKForCE sErViCEs
140 East 300 South, P.O. BOX 45233, Salt Lake City, Utah 84145-0233
1-801-526-9235 option 5; 1-800-222-2857 option 5
you may submit this report online at our web site:
EMPLOYER NAME:
EMPLOYER’S UTAH
REGISTRATION NUMBER:
If your report is HAND PRINTED, please use UPPER CASE
QUARTER ENDING DATE
only and in a block style similar to this sample. USE BLACK
INK PEN ONLY. Thank you.
ENTER GRAND TOTALS ON PAGE 1 ONLY
Total Wages from line 3
NOTE: These two
Total Wages reported on
A B
C D E
F G H I
J K
L M N O P Q R
of Contribution Report
Totals should agree
Wage Lists (all pages)
S T U V
X Y Z 0
1
2
3
4
5
6
7
8
9
W
SOCIAL SECURITY
EMPLOYEE NAME
TOTAL WAGES PAID EACH
ACCOUNT NUMBER
EMPLOYEE IN THIS QUARTER
First initial
Middle Initial
Last Name
(WHOLE DOLLARS ONLY)
TOTAL OF THIS PAGE ONLY
Please do not submit photocopies of wage list forms.
Read reverse side for how to obtain additional forms.
Page No.____________________
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