Form Ui-111 - Montana Unemployment Insurance Electronic Media Reporting Application printable pdf download

Form Ui-111 - Montana Unemployment Insurance Electronic Media Reporting Application

Unemployment Insurance Contributions Bureau

MONTANA UNEMPLOYMENT INSURANCE

PO Box 6339

ELECTRONIC MEDIA REPORTING

Helena MT 59604-6339

Telephone (406) 444-3834

APPLICATION

Fax (406) 444-0629

Employer Business Name or Agent’s Name

UI Account No.

Address: (No., Street)

City, State and Zip Code

If reporting for multiple employers,

Wage information only

Report information is:

number of employers:

Wage and Tax information

Diskette

Spreadsheets

FTP Secure File Transfer

For Diskettes/CD, check on each line:

Diskette Size:

3 ½”

Density:

Low Density

High Density

For PAYROLL Information, contact: (Name)

Title

Phone No.

For TECHNICAL Information, contact: (Name)

Title

Phone No.

I am requesting approval to report employee wage and/or employer tax information on diskette, CD,

spreadsheet or FTP Secure File Transfer. I am enclosing a test copy clearly marked “FOR TEST

PURPOSES ONLY”.

Employer Signature: __________________________________________________________

Title: _____________________________________ Date: ___________________________

Please allow three months for testing.

FOR AGENCY USE ONLY

Approved

Denied

Reason: ___________________________________________________________________

Signature: _________________________________ Date: __________________________

UI-111

(Rev. 3/2009)

Form Ui-111 - Montana Unemployment Insurance Electronic Media Reporting Application

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