Employer'S Contribution And Payroll Report Form - Iowa Workforce Development - 2007 Page 3
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4Employer's Contribution & Payroll Report
Iowa Account
Qtr
Year
65-5300 (REV 2007)
Number
THIS IS A 3 PAGE DOCUMENT. ALL 3 PAGES
MUST BE COMPLETED AND FORWARDED TO
IOWA WORKFORCE DEVELOPMENT.
Labor Market Information
21. Enter number of employees paid wages this quarter
3rd month
1st month
2nd month
22. Enter number of employees paid wages during the pay period which
includes the 12th day of each month in this quarter.
23. Identify Iowa Worksites
For Multiple Worksites complete the "Multiple Worksites Report". If not received,
Single Worksite
please call telephone number below.
County Number
24. Amount of pay which exceeds regular and recurring payment to employees; such
as bonus, executive pay, severance pay etc.
25. If the number of employees increased or decreased during
the quarter for any of the following reasons, please check
the box(es) to indicate the reason(s).
1. Seasonal Change
3. Layoff
5. Worksite Opening
2. Labor Dispute
4. Recall
6. Worksite Closing
If you have any questions regarding Labor Market Information, please call at 1-800-532-1249 or by fax 1-515-281-8195.
26. If there are 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
Authorized
Name
Signature
Preparer's Title
Print Signer's Name
Preparer's
Signer's Title
Telephone Number
Business
Preparer's E-mail
Telephone
Address
Business E-mail
Date Submitted
Address
FOR ADMINISTRATIVE USE ONLY
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