Quarterly Report Of Wages Paid - Louisiana Department Of Labor - 2001

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This form is semi-interactive. It may be filled out on-line but must be printed and mailed in.
IMPORTANT: Complete the Employer Wage Report first. The total entered on Line 10 of that document
is the total wages for this quarter to be entered on Line 8 of this document.
1. Due Date
2. Federal ID No.
3. Year/ Qtr
4. State ID No.
5. Rate %
QUARTERLY REPORT OF WAGES PAID
6. Number of covered workers who worked or
.00
received pay for the payroll period which
8. TOTAL WAGES THIS QUARTER
includes the 12th of the month
1st
2nd
3rd
.00
9. WAGES IN EXCESS THIS QUARTER
.00
7. EMPLOYER NAME, DBA & ADDRESS
10. TAXABLE WAGES THIS QUARTER
11. CONTRIBUTIONS (TAX )DUE
12. SUBTRACT TAX OVERPAYMENT AMOUNT
13. ADD PRIOR QUARTER DELINQUENCY
14. TOTAL AMOUNT OF REMITTANCE
DO NOT SEND CASH OR CHANGE
I certify the information on this form is true and accurate.
MAIL TO: LOUISIANA DEPARTMENT OF LABOR
Signature
Phone:
OFFICE OF REGULATORY SERVICES
CASHIERING UNIT
Title
Date:
P O BOX 94050
LDOL-ES4/WEB
BATON ROUGE, La. 70804-9050
Rev. 7/2001
The Employer Wage Report (LDOL-ES4 B/WEB) must be attached to this form.

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