Health Insurance Contribution Form - Massachusetts Division Of Unemployment Assistance

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HEALTH INSURANCE
Division of
Telephone: (617) 626-5060
CONTRIBUTION
Unemployment
Assistance
REVENUE SERVICE
5 th Floor
19 Staniford Street
Boston, Ma 02114-2589
DISCREPANCY NOTICE
EMPLOYER QUARTERLY CONTRIBUTION REPORT FOR QUARTER ENDING
DUE
DATE:
EMPLOYER NO.
BATCH NO.
SEQUENCE NO.
AUX. CODE
ANNUAL
INTEREST RATE
BEFORE COMPLETING THIS REPORT, IF THERE IS A DISCREPANCY,PLEASE SEE REVERSE SIDE FOR "INSTRUCTIONS TO EMPLOYER "
A
B
C
D
COMPUTED
AS REPORTED
AS CORRECTED
INCREASE
DECREASE
25/
55/
TOTAL
COMPENSATION
26/
56/
LESS:
EXCESS
COMPENSATION
TOTAL TAXABLE
WAGES
CONTRIBUTION
RATE
CONTRIBUTION
DUE
CONTRIBUTION
1. ADDITIONAL CONTRIBUTION DUE
PAID
2. CONTRIBUTION INTEREST DUE
CONTRIBUTION
3. ADDITIONAL CONTRIBUTION
4. OVERPAID
INTEREST DUE
AMOUNT DUE ( 1 + 2 )
CONTRIBUTION
CONTRIBUTION
INTEREST PAID
PENALTY DUE
PENALTY PAID
5. AMOUNT DUE--------------------------------------->
NET TOTAL
6. TOTAL OVERPAID ----------------------------------------------------------------->
7. CLAIM FOR REFUND
MONTH 1
MONTH 2
MONTH 3
8. ENTER CORRECT EMPLOYEE COUNT
REASON FOR REFUND: _____________________________________________________________________________
__________________________________________________________________________________________________
CERTIFICATE (MUST BE EXECUTED) I certify the information in this report is true and correct to the best of my knowledge
and belief, that the wages reported represent all the wages paid during this quarter for employment covered by the Law, and
that no part of the contribution reported was, or is to be deducted from workers' wages. THIS STATEMENT IS MADE UNDER
THE PENALTIES OF PERJURY.
Signed this _________ day of _______ 20_____ Name:___________________________________________________
REPORT MUST BE SIGNED
Title:___________________________________________________
THIS FORM IS TO BE USED ONLY FOR CORRECTING REPORT PREVIOUSLY SUBMITTED.
DET02A/BB/04/98(Form 1711-HI)rev 02-18-04

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