Form Uc-5-Se - Seasonal Employer Quarterly Payroll Report - Continuation - Ndiana Department Of Workforce Development

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S EASONAL EMPLOYER QUARTERLY PAYROLL
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N. SENATE AVE, RM SE003
REPORT - CONTINUATION
INDIANAPOLIS, IN 46204-2201
DWD Form UC-5-SE
State Form 21390 (R2 / 3-10)
CONFIDENTIAL RECORD
Pursuant to IC 22-4-19-6, IC 4-1-6
TO BE COMPLETED BY SEASONAL EMPLOYER ONLY.
To Employer:
To obtain additional copies of this Seasonal Employer Quarterly Payroll Report-Continuation Sheet, please submit your request in writing to
above address ATTN: Wage Record, RM SE003.
Name of Employer
Indiana Account Number
Date Quarter Ended
Page Number
(mm/dd/yyyy)
NOTE: Form UC-5A, Quarterly Payroll Report, must
Under Indiana Account Number, show the Account Number which appears on
accompany this form.
Form UC-1 and UC-5A. Do not show the Federal Identification Number.
Detailed instructions for preparation of this
form are given in the cover letter.
(3) All Remuneration
(1) Social Security Number
(4) Seasonal
(2) Name of Employee (Please type or print.)
Including Excess Over
Code Number
000
00
0000
$7,000.00
Total of all remuneration listed in column (3) must be
TOTAL FOR THIS PAGE
shown on last page and under item D of Form UC-5A.

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