Form 65-5300 - Employer'S Contribution & Payroll Report - State Of Iowa - 2000
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1Employer's Contribution & Payroll Report
65-5300 (2000)
12. Page ___________ of ___________
Iowa Workforce Development - 1000 East Grand Avenue
Des Moines, Iowa 50319-0209
Telephone (515) 281-5339
Payment Computation (If no wages this quarter, see instructions)
13.
1. Total Wages (All Pages) ............................. $ ______________________
Iowa Account Number
For Months Of
Qtr Yr
2. Taxable Wages (All Pages) ......................... $ ______________________
3. Contribution Due
Year
Taxable Wage Base
Contribution Rate
Surcharge Rate
(Item 2 X
) ..................... $ ______________________
4. Surcharge Due
Federal ID Number
Delinquent After Date
(Item 2 X
) ................... $ ______________________
5. Total lines 3 and 4 ...................................... $ ______________________
Employer Name & Address
6. Interest Due (See Instructions) ................... $ ______________________
7. Penalty Due (See Instructions) ................... $ ______________________
8. Total Due (Items 5, 6 and 7) ..................... $ ______________________
9. Amount Due from Previous Quarter .......... $ ______________________
10. Credit Due from Previous Quarter ............. $ ______________________
11. Amount Paid. ............................................. $ _______________________
(Make check payable to Iowa Workforce Development)
If total due is less than $1.00, no payment is required.
14.
Payroll Listing
Check if payroll reporting is by:
magnetic tape
cartridge
diskette
15. Social Security Number
17. Total Wages Paid
18. Taxable Wages Paid
16. Last Name
First Name
MI
19. Totals For This Page
Labor Market Information
DEPARTMENTAL USE ONLY
20. Enter number of employees
21. For each month, report the number of covered workers who
1st Month
2nd Month
3rd Month
Do not write in shaded area.
paid wages
worked during or received pay for the payroll period which
this quarter.
includes the 12th of the month.
23. Amount of pay which exceeds regular and recurring payments to employees;
22. Identify Iowa Worksites
such as bonus, executive pay, severance pay, etc.,
. . . . . . . . . . . . . . . . . . . $
Single Worksite
24. If the number of employees increased or
County Number
1.
seasonal change
3.
layoff
5.
worksite opening
decreased during the quarter for any of the
following reasons, please check the box(es)
2.
labor dispute
4.
recall
6.
worksite closing
For Multiple Worksites
to indicate the reason(s).
Complete the "Multiple Worksite
If you have questions regarding Labor Market Information, please contact Research & Information
Report". If not received, please
Services at 1-800-532-1249 (in Iowa) or 1-515-281-8415 (outside Iowa).
call the telephone number at right.¹
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25. If there are any CHANGES in your FEDERAL ID NUMBER, ACCOUNT NAME, ADDRESS, OR OWNERSHIP, please complete and return the "EMPLOYER'S NOTICE OF CHANGE".
I CERTIFY that this report is true and correct and that no part of the contribution was deducted from any employee's wages.
Print Preparer's Name
Preparer's Telephone Number
Authorized Signature
Title
Business Telephone
Date
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