Form 1110-A - Employer Status Report Page 3

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List below the number of individuals in your employ in Massachusetts within each calendar week. Include full and part time employees, also paid offi cers if
a corporation. An individual proprietor or a partner should not be counted as an employee. Show total Massachusetts payroll for each calendar
RECORD OF MASSACHUSETTS EMPLOYMENT IN CURRENT CALENDAR YEAR
ENTER YEAR
FEBRUARY
MARCH
MAY
JUNE
JANUARY
APRIL
Week
Ending
Number
Employed
AUGUST
SEPTEMBER
NOVEMBER
DECEMBER
JULY
OCTOBER
Week
Ending
Number
Employed
TOTAL WAGES
1st QTR. $
2nd QTR. $
3rd QTR. $
4th QTR. $
ENTER YEAR
RECORD OF MASSACHUSETTS EMPLOYMENT IN PRECEDING CALENDAR YEAR
FEBRUARY
MARCH
MAY
JUNE
JANUARY
APRIL
Week
Ending
Number
Employed
AUGUST
SEPTEMBER
NOVEMBER
DECEMBER
JULY
OCTOBER
Week
Ending
Number
Employed
TOTAL WAGES
1st QTR. $
2nd QTR. $
3rd QTR. $
4th QTR. $
RECORD OF MASSACHUSETTS EMPLOYMENT IN PRECEDING CALENDAR YEAR
ENTER YEAR
FEBRUARY
MARCH
MAY
JUNE
JANUARY
APRIL
Week
Ending
Number
Employed
AUGUST
SEPTEMBER
NOVEMBER
DECEMBER
JULY
OCTOBER
Week
Ending
Number
Employed
TOTAL WAGES
1st QTR. $
2nd QTR. $
3rd QTR. $
4th QTR. $
PREDECESSOR: I hereby certify that all information submitted by the successor is true in accordance with the transfer.
Title:
Signature:
owner, partner or offi cer
THIS REPORT MUST BE SIGNED BY THE OWNER, A PARTNER OR CORPORATE OFFICER
I certify, under penalties of perjury, that all statements made hereon are true to the best of my knowledge and belief.
Name of employing unit:
Date:
Signature:
Title:
1110-A Rev. 08-05

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