Form Ncui 101 - Employerr'S Quarterly Tax And Wage Report
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1
2EMPLOYER'S QUARTERLY
EMPLOYMENT SECURITY COMMISSION
OF NORTH CAROLINA
TAX AND WAGE REPORT
P. 0. BOX 26504
RALEIGH, NC 27611-6504
DUE DATE
ACCOUNT NUMBER
QUARTER ENDING
PLEASE TYPE THIS REPORT
QTY/YR
TAX RATE
%
1. NUMBER OF COVERED WORKERS
1ST MONTH
2ND MONTH
3RD MONTH
WHO WORKED DURING OR
RECEIVED PAY FOR THE PAYROLL
PERIOD WHICH INCLUDES
THE 12TH OF THE MONTH
2. WAGES PAID THIS QUARTER
SUBJECT TO THE LAW
3. LESS EXCESS WAGES
FOR AGENCY USE ONLY
4. WAGES SUBJECT TO TAX
CK AMOUNT
DATE
INITIAL
COLL.
5. TAX DUE FOR THIS QUARTER
R/CK
LFP.W
LPP.W
6. INTEREST
7. PENALTY - LATE FILING
8. PENALTY LATE PAYMENT
9. AMOUNT OF REMITTANCE
PAYABLE TO:
EMPLOYMENT SECURITY COMMISSION
. IF INCORRECT, ENTER CORRECT
OUR RECORDS SHOW YOUR FEDERAL TAX NUMBER AS
NUMBER HERE:
. IF ANY CHANGES OCCURRED IN THE OWNERSHIP, TELEPHONE NUMBER OR
ADDRESS, COMPLETE FORM NCUI 101-A.
10. SOCIAL SECURITY NUMBER
11. EMPLOYEE NAME
12. SEASONAL
13. WAGES PAID
THIS QUARTER
RETURN
THIS
FORM
14. PAGE TOTAL
THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
TITLE
TELEPHONE NUMBER
DATE
THIS REPORT MUST BE FILED BY THE DUE DATE TO AVOID PENALTIES AND INTEREST.
NCUI 101
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