Form Dol-4a - Annual Tax And Wage Report For Domestic Employment Page 2
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1
2ANNUAL TAX AND WAGE REPORT FOR DOMESTIC EMPLOYMENT -
* 4 9 9 9 9 *
PART II
*49999*
GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234
Tel. (404) 232-3245
ELECTRONIC FORM PROCESSING
DOL Account Number
Year
Total Tax Rate
Form must be Filed By
x x x x
F irst Quarter
Second Quarter
Third Quarter
Fourth Quarter
DO NOT staple any items to this page.
f i
f
x x
1.
REPORTABLE GROSS WAGES
Total
Paid Each Quarter
2.
MINUS
Non-Taxable Wages Paid Each Quarter
3.
TAXABLE WAGES
Paid Each Quarter
4.
Contribution Tax Due:
taxable wages
X
(line 3)
5.
Administrative Assessment Due:
taxable wages
(line 3)
X
6.
Total Amount Due:
(
SUM of lines 4 and 5)
7.
Taxes Previously Paid (if any)
8.
BALANCE DUE:
(
Line 6 minus 7)
$
9. ANNUAL TAX DUE
:
(SUM of line 8 for all quarters listed on this report)
$
10.
If report is late, amount of Interest due
:(See instructions)
$
11. 11.
If report is late, amount of Penalty due
:(See instructions)
$
12. TOTAL AMOUNT DUE
(
SUM of lines 9 thru 11)
Return these forms (Parts I & II) with
check payable to GA DEPT of LABOR or
visit for online
UNLESS PARTS I & II OF THIS REPORT ARE FILED AND THE TOTAL AMOUNT
/
/
payment options.
DUE IS PAID, A FI. FA. (TAX LIEN) WILL BE ISSUED AS REQUIRED BY LAW.
FOR DEPT USE ONLY
EMPLOYER CHANGE REQUEST
ANY
- If
of the following items have changed, please complete the appropriate information below. Phone (404) 232-3301
B
A
. If your PHYSICAL LOCATION has changed or is incorrect, enter
. If your MAILING ADDRESS has changed or is incorrect, enter
the correct information below:
the correct information below:
(Street Address)
(Street Address)
(Street Address)
(Street Address)
(City)
(State)
(Zip)
(City)
(State)
(Zip)
(
(
)
)
(Phone)
(Phone)
C
E
. If you no longer have domestic workers, please provide the last
. E-mail address:
date you had such workers:
/
/
Effective Date (MM/DD/YY)
D
. If your Federal Employer Identification Number has changed, enter
the correct number below:
I certify that the information contained in this report and any
subsequent pages attached is true and correct and that no part of
the tax was or is to be deducted from the worker's wages.
(
)
Signature and title of individual responsible for information provided
Phone Number
Date
DOL-4A (8/14)
EL6102
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