Form Uia 1028 - Employer'S Quarterly Wage/tax Report - Michigan Department Of Licensing And Regulatory Affairs

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State of Michigan
Authorized by
UIA 1028
Department of Licensing and Regulatory Affairs
MCL 421.1 et seq.
(Rev. 06-12)
Unemployment Insurance Agency
3024 W Grand Blvd, Suite 11-500, Detroit, MI 48202
Rick Snyder
Steve Arwood
GOVERNOR
DIRECTOR
Reset Form
Enter Employer Name and
Mail To:
Address here:
Unemployment Insurance Agency
Tax Office
PO Box 33598
Detroit, MI 48232-5598
Employer’s Quarterly Wage/Tax Report
YOU MUST FILE THIS REPORT EVEN IF YOU ARE UNABLE TO PAY OR HAVE NO PAYROLL FOR THE QUARTER.
For details about completing this report see the instructions page. Only amounts over $5 may be subject to active
collection.
Employer Type: Contributing
(Complete Sections 1, 2, 3 & 4)
Reimbursing
(Complete Sections 1, 2 & 4)
Check this box if this is an Amended report. Indicate quarter and year________________________
If Amended, select one of the following reasons: Not liable
Miscalculated wages
Used wrong taxable wage limit
Other
_________________________________________
Provide the number of all full-time employees and
SECTION 1
part-time employees who worked during or received
UIA Employer Account No: _____________________________
th
pay for the pay period which includes the 12
of the
st
nd
rd
FEIN: ______________________________________________
1
Month
2
Month
3
Month
Quarter Ending Date (mm/dd/yyyy):_______________________
SECTION 2
LIST SSN IN ASCENDING ORDER
Family
Employee
Gross Wages Paid
Delete
Owned
Social Security No.
Employee Last Name
Employee First Name
Enter
“X”
Middle
This Quarter
“F”
Initial
$ 0.00
Total Gross Wages (Page 1):
If more lines are needed to enter employee information,
continue to Section 2 on back of form. When finished
entering employees, continue to Section 3 for Contributing
Employers or Section 4 for Reimbursing Employers.
_____________________________________________________________________________________________
For UIA Use Only. Do Not Write Below Line.

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