Employer'S Contribution And Payroll Report Form - Iowa Workforce Development - 2007

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65-5300
Employer's Contribution & Payroll Report
65-5300
(REV 2007)
Iowa Workforce Development - Attn: Tax Bureau
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
Telephone (515) 281-5339
THIS IS A 3 PAGE DOCUMENT. ALL 3 PAGES MUST BE
COMPLETED AND FORWARDED TO IOWA WORKFORCE DEVELOPMENT.
Payment Computation (If no wages this quarter, see instructions)
For Months Of
Qtr
Year
14. Iowa Account Number
1. Total Wages
(All Pages)
Federal Identification
Taxable Wage
Delinquent After Date
2. Taxable Wages
Number
Base
(All Pages)
3. State Experience Due
(Line 2 X
)
Surcharge Rate
Reserve Rate
State Experience Rate
4. Reserve Fund Due
(Line 2 X
)
Total Rate:
5. Surcharge Due
(Line 2 X
)
6. Total lines 3, 4 and 5
Employer Name & Address
7. Interest Due
(See Instructions)
8. Penalty Due
(See Instructions)
9. Total Due this Report
(Lines 6 + 7 + 8)
10. Amount Due from
Previous Quarter
(Make check payable to Iowa Workforce Development)
11. Credit Due from
Previous Quarter
If total due is less than $1.00 no payment is required;
however, you are still required to file this report with
12A. Total Due
Iowa Workforce Development. Failure to timely file this
(Lines 9 + 10 - 11)
report may result in a penalty.
12B. Amount Paid
Equal Opportunity Employer/Program
Auxillary aids and services are available upon request
12C. Payment
Credit Card
eCheck
Credit Memo
to individuals with disabilities
Method:
For deaf and hard of hearing, use Relay 711
Paper Check
None
13. Page 1 of

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