QUARTERLY CONTRIBUTION
RETURN AND REPORT OF WAGES
(CONTINUATION)
009C0111
PLEASE TYPE THIS FORM PER INSTRUCTIONS ON REVERSE
Page number _______ of ______
You must FILE this report even if you had no payroll. If you had no payroll, complete Items C or
YR
QTR
D and P.
DELINQUENT IF
QUARTER
NOT POSTMARKED
ENDED
DUE
OR RECEIVED BY
EMPLOYER ACCOUNT NO.
DO NOT ALTER THIS AREA
P1
C
T
S
W
A
EFFECTIVE DATE
Mo.
Day
Yr.
WIC
A. EMPLOYEES full-time and part-time who worked during
or received pay subject to UI for the payroll period which
includes the 12th of the month.
1st Mo.
2nd Mo.
3rd Mo.
Check this box if you are reporting ONLY Voluntary Plan DI wages on this page.
C.
NO PAYROLL
D.
OUT OF BUSINESS/NO EMPLOYEES
B.
Report PIT Wages and PIT Withheld, if appropriate. (See instructions for Item B.)
Date
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G
.
T
O
T
A
L
S
U
B
J
E
C
T
W
A
G
E
S
. H
P
T I
W
A
G
E
S
. I
P
T I
W
T I
H
H
E
L
D
.
. . . . . .
.
.
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G
.
T
O
T
A
L
S
U
B
J
E
C
T
W
A
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S
. H
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W
A
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S
. I
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T I
W
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H
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L
D
.
.
. . . . .
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G
.
T
O
T
A
L
S
U
B
J
E
C
T
W
A
G
E
S
. H
P
T I
W
A
G
E
S
I. PIT WITHHELD
.
.
. . . . . .
.
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G. TOTAL SUBJECT WAGES
H. PIT WAGES
I. PIT
WITHHELD
.
. . . . . .
.
.
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G
.
T
O
T
A
L
S
U
B
J
E
C
T
W
A
G
E
S
. H
P
T I
W
A
G
E
S
I. PIT WITHHELD
.
.
. . . . . .
.
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
H. PIT WAGES
G. TOTAL SUBJECT WAGES
I. PIT WITHHELD
.
. . . . . .
.
.
E. SOCIAL SECURITY NUMBER
F. EMPLOYEE NAME (FIRST NAME)
(M.I.) (LAST NAME)
G
.
T
O
T
A
L
S
U
B
J
E
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T
W
A
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. I
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D
.
.
.
. J
T
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. K
T
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T
A
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W
A
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S
T
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S I
P
A
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L. TOTAL PIT WITHHELD THIS PAGE
0.00
0.00
0.00
.
.
.
M
.
G
R
A
N
D
T
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T
A
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A
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. N
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A
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.
G
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A
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D TOTAL PIT WITHHELD
.
.
.
P. I declare that the information herein is true and correct to the best of my knowledge and belief.
Preparer’s
Signature
Title
Phone (
)
Date
(Owner, Accountant, Preparer, etc.)
MAIL TO: State of California / Employment Development Department / P.O. Box 989071 / West Sacramento CA 95798-9071
CU
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