Form Modes-10b - Missouri Quarterly Wage Report - Continuation Sheet
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1MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
P.O. Box 888
DIVISION OF EMPLOYMENT SECURITY
Jefferson City, MO 65102-0888
Missouri Quarterly Wage Report
CONTINUATION SHEET
Print in this space employer’s name and account number as shown on
Calendar Quarter/Year
Form MODES-4 Missouri Quarterly Contribution and Wage Report
Type or print in ink
First
Middle
17. Worker Name
16. Social Security Number
18. Total Wages Paid This Quarter
19. Probationary
Initial
Initial
Last Name
20. Page ______ of ______ Pages
TOTAL THIS PAGE
Be sure that each page carries employer’s name, account number, page number and calendar quarter and year.
Return the original completed form to the Division of Employment Security, P.O. Box 888, Jefferson City, MO 65102-0888.
Retain copy for your file.
MODES-10B (6-99) AI
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