Form Dws-Ark-209bs - Employer'S Quarterly Contribution And Wage Report
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EMPLOYER’S QUARTERLY CONTRIBUTION AND WAGE REPORT
ARKANSAS DEPARTMENT OF WORKFORCE SERVICES
P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3798
SEASONAL REIMBURSABLE
DWS ID NUMBER
DATE QUARTER ENDED
FEDERAL ID NUMBERD
SEASONAL CODE
SEASONAL DATES
Check box and return if no wages paid c
PART A.
1st mo
2nd mo
3rd mo
1. Number of employees in the pay period including the 12th of:
of qtr _________ of qtr _________ of qtr _______
2. Total of all wages paid for personal services, including bonuses/commissions ............... $ _ ______________.____
3. Penalty (see instructions) ..................................................................................................... $<_______________.____
4. Amount of remmittance (make payable to Arkansas Department of Workforce Services) .... $________________.____
CASHIER’S STAMP
DO NOT ALTER THIS BARCODED FORM
Initial
PART B.
Amt received
Enter the SSN, first name, middle initial, last name and
total wages paid to each employee during the calendar
quarter in the space provided below (continuation sheet
Penalty code
provided).
WAGES PAID
WAGES PAID
IN SEASON
OUT OF SEASON
SOCIAL SECURITY NO.
FIRST NAME, INITIAL & LAST NAME OF EMPLOYEE
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$
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$
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$
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$
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$
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$
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$
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$
PAGE ONE OF _______ PAGE(S)
TOTAL WAGES FOR THIS PAGE
TOTAL NO. OF EMPLOYEES ON THIS REPORT __________
I HEREBY CERTIFY THIS REPORT IS TRUE AND CORRECT.
SIGNATURE ______________________________TITLE __________________________ DATE _______________ TELEPHONE __________________
DWS-ARK-209BS
(REV. 06-06)
MAINTAIN COPY FOR YOUR RECORDS
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