State Form 54256 - Quarterly Payroll Report
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1
2QUARTERLY PAYROLL REPORT
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N. Senate Ave., INDIANAPOLIS IN 46204-2277
State Form 54256 (R4 / 7-15) / DWD Form UC-5A
BATCH Number
DOC Number
This agency is requesting disclosure of your Social Security number in accordance with IC
4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
A. Period Covered
B. Total Number of Employees
C. TOTAL INDIANA PAYROLL
Total of Column 3 for all pages
(Must agree with item 2 on Form UC-1)
Area Code
D. Contact Name and Telephone Number
(
)
$
E. Employer Information
F. Report Pages
SUTA Account Number
FEIN Number
Location Code
Page _______ of _______
Quarter
Year
Employer
(Check only one.)
Address
1
2
3
4
City
State
ZIP Code
(Abbreviation )
(1) SOCIAL SECURITY NUMBER
(3) ALL REMUNERATION
(2) NAME OF EMPLOYEE
000
00
0000
(Including Excess Over Taxable Limit)
(
Please type or print.)
$
TOTAL FROM THIS PAGE
Total of all remuneration listed in column (3) must be shown on last page and under item C of this form.
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