Form Ui-5 - Montana Employer'S Unemployment Insurance (Ui) Quarterly Wage Report Page 2

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MONTANA UNEMPLOYMENT INSURANCE
EMPLOYEE WAGE LISTING - Form UI-5A
Use this form (or a facsimile) as a continuation sheet for the UI employee wage listing on the Montana Employer's Unemployment Insurance
Quarterly Wage Report - Form UI-5 (Step 2).
Employer's Name and Address:
UI Account No:
FEIN:
Quarter End:
Name of Employee
Employee’s Social
Total Wages Paid
Excess Wages
Security Number
this Quarter
This Quarter
Last Name
First Name
Totals
Page No._______ of _________
For additional UI Employee Wage Listing Forms UI5A, please photocopy a blank form or call 1-800-550-1513. Attach the completed
UI5A to the UI Quarterly Wage Report and mail to the Unemployment Insurance Contributions Bureau PO Box 6339, Helena, MT 59604-6339
FORM UI5A
Rev. 6/05

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