Form 65-5300 - Employer'S Contribution And Payroll Report Form - Iowa Workforce Development - 2006
ADVERTISEMENT
1
2Employer's Contribution & Payroll Report
65-5300 (2006)
13. Page ________ of ________
Iowa Workforce Development - Attn: Tax Bureau
I
I
I
I
I
I
I
O
O
O
O
O
O
O
W
W
W
W
W
W
W
A
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
Telephone (515) 281-5339
®
®
®
®
®
®
®
Payment Computation (If no wages this quarter, see instructions)
14.
1. Total Wages (All Pages) ...................... $ _____________________
Iowa Account Number
For Months Of
Qtr Yr
2. Taxable Wages (All Pages) .................. $ _____________________
3. State Experience Due
Federal Identification Number
Taxable Wage Base
Delinquent After Date
(Item 2 X
0.00720) ................. $ _____________________
4. Reserve Fund Due
State Experience Rate
Reserve Rate
Surcharge Rate
(Item 2 X
0.00180) ................. $ _____________________
5. Surcharge Due
(Item 2 X
0.00035) ................. $ _____________________
Total Rate:
6. Total lines 3, 4 and 5 ........................... $ _____________________
7. Interest Due (See Instructions) ............ $ _____________________
Employer Name & Address
8. Penalty Due (See Instructions) ............ $ _____________________
9. Total Due (Items 6, 7 and 8) ................ $ _____________________
10. Amount Due from Previous Quarter ...... $ _____________________
11. Credit Due from Previous Quarter ......... $ _____________________
12. Amount Paid. ...................................... $ _____________________
(Make check payable to Iowa Workforce Development)
If total due is less than $1.00, no payment is required; however, you are still required to file this report with Iowa
Workforce Development. Failure to file this report will result in a penalty.
Payroll Listing
15.
Check if payroll reporting is by:
cartridge
diskette
16.Social Security Number
17. Last Name First Name
MI
18. Total Wages Paid 19. Taxable Wages Paid
20. Totals For This Page
Labor Market Information
DEPARTMENTAL USE ONLY
21. Enter number of employees
22.For each month, report the number of covered workers
1st Month
2nd Month
3rd Month
Do not write in shaded area.
paid wages
who worked during or received pay for the payroll
this quarter
period which includes the 12th of the month
24. Amount of pay which exceeds regular and recurring payments to employees;
23.Identify Iowa Worksites
such as bonus, executive pay, severance pay, etc.,
. . . . . . . . . $
Single Worksite
County Number
25. If the number of employees increased or
1.
seasonal change 3.
layoff
5.
worksite opening
decreased during the quarter for any of the
For Multiple Worksites
following reasons, please check the
2.
labor dispute
4.
recall
6.
worksite closing
Complete the "Multiple
box(es) to indicate the reason(s).
Worksite Report". If not
If you have questions regarding Labor Market Information, please contact Policy and
received, please call the
Information Services at 1-800-532-1249 or by fax 1-515-281-8195.
telephone number at right.
F
E
C
R
FD
RTE
UNP
EC
CHG
LD
26. If there are any CHANGES in your FEDERAL ID NUMBER, ACCOUNT NAME, ADDRESS, OR OWNERSHIP, please complete and return the "EMPLOYER'S NOTICE OF CHANGE".
I CERTIFY that this report is true and correct and that no part of the contribution was deducted from any employee's wages.
Print Preparer's Name
Preparer's Telephone Number
Authorized Signature
Title
Business Telephone
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal