State Form 54256 - Quarterly Payroll Report Page 2

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QUARTERLY PAYROLL
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N SENATE AVE RM SE003 INDIANAPOLIS IN 46204-2277
REPORT - CONTINUATION
For Wage Reporting Assistance Call 317-232-7399
State Form 4384 (R6 / 11-11) / DWD Form UC-5B
CONFIDENTIAL RECORD Pursuant to IC 22-4-19-6, IC 4-1-6
TO EMPLOYER:
See instructions for preparation of Quarterly Payroll Report on the back of UC-5A, State Form 54256.
Name of Employer
Page
of
Federal Identification Number
Location Code
Date Quarter Ended
SUTA Account Number*
* Under SUTA Account No., show the Account Number
NOTE:
Form UC-5A, Quarterly Payroll Report must accompany this
which appears on Form UC-1. Do not show
form. Detailed instructions for preperation of both forms are
the Federal Identification Number in this column.
shown on the reverse side of Form UC-5A.
(1)
SOCIAL SECURITY NUMBER
(2) NAME OF EMPLOYEE (Please type or print)
(3)
GROSS WAGES
000
00
0000
Total for this page
Total for all pages (must equal box C on UC5A)

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