Form Dol-4n - Employer'S Quarterly Tax And Wage Report - Georgia Department Of Labor Page 2
ADVERTISEMENT
1
2EMPLOYER'S QUARTERLY TAX AND WAGE REPORT - PART II
GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234
Tel. (404) 232-3001
REPORT FOR THE QUARTER ENDING
ELECTRONIC FORM PROCESSING
DO NOT staple any items to this page.
Use BLACK ink only.
DOL Account Number
Qtr/Yr
Total Tax Rate
Form must be Filed By
x x x x
FORM ENTRY EXAMPLE
:
1
2
6
9
0
0
,
,
.
(PLEASE PRINT CLEARLY)
x x
1.
For each month, report the number of
covered workers who worked during or
received
pay
for
the
payroll
period
which includes the 12th of the month
(1ST MONTH)
(3RD MONTH)
(2ND MONTH)
$
,
,
.
2.
GROSS WAGES
Total
Paid This Quarter
(Combine all wages into one total.)
3.
,
,
.
MINUS
Non-Taxable Wages Paid This Quarter
4.
,
,
.
TAXABLE WAGES
Paid This Quarter
PARTS I & II OF THIS
5.
Contribution Tax Due:
,
,
.
taxable wages
X
(line 4)
REPORT MUST ALWAYS
BE SUBMITTED.
6.
Administrative Assessment Due:
,
,
.
ENTER ZEROES ON LINE
X
taxable wages
(line 4)
2 IF NO WAGES WERE
7.
Interest On Lines 5 and 6:
See Instructions
,
,
.
PAID THIS QUARTER.
Due after
8.
Penalty is for filing late, not based on total
,
,
.
Due after
amount due
:(See Instructions)
,
,
.
9.
Balance as of
$
10.
TOTAL AMOUNT DUE :
,
,
.
(
SUM of lines 5 thru 9)
Return these original forms (Parts I & II)
UNLESS PARTS I & II OF THIS REPORT ARE FILED AND THE TOTAL AMOUNT
with check payable to GA DEPT of LABOR.
DUE IS PAID, A FI. FA. (TAX LIEN) WILL BE ISSUED AS REQUIRED BY LAW.
FOR DEPT USE ONLY
EMPLOYER CHANGE REQUEST
ANY
Phone (404) 232-3301
- If
of the following items have changed, please complete the appropriate information below.
A
D
. If you are a new employer, or the name of your business or MAILING
. If your business was discontinued or if a change in
ADDRESS has changed, or is incorrect, enter the correct information
ownership has occurred, please complete the following
:
below:
(Check One)
Business
Entire Business
Corporation
Discontinued
Sold
Formed
(Business Name)
Partners Added
(Street Address)
or Withdrawn
Merger
Partial Sale
Corporate Name Change Only
(Attach copy of Amendment to Charter)
(Street Address)
Other
(Attach Explanation)
(City)
(State)
(Zip)
/
/
Effective Date (MM/DD/YY)
(Phone)
B
. If the PRINCIPAL LOCATION of your business operations in GEORGIA
(New Owner's Name)
has changed, enter the correct address below (DO NOT use a P.O. Box
number for Principal Location):
(Street Address)
(Street Address)
(Street Address)
(Zip)
(City)
(State)
(Street Address)
(Phone)
(City)
(State)
(Zip)
(Phone)
C
. If the Federal Identification number listed below is incorrect or if you
have been assigned a new number, list the correct number in the spaces
provided:
If the Federal ID number changed due to a change in ownership, complete section D.
I certify that the information contained in this report and any subsequent pages attached is true
(Employer Name and Address)
and correct and that no part of the tax was or is to be deducted from the worker's wages.
Signature and title of individual responsible for information provided
Phone No.
Date
DOL-4N (R-11/06)
EL3104
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal