Employer'S Contribution And Wage Report Reimbursable - Job Service North Dakota
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1EMPLOYER'S CONTRIBUTION AND WAGE REPORT -
JOB SERVICE NORTH DAKOTA
REIMBURSABLE
UI/TAX & FIELD SERVICES
PO BOX 5507 BISMARCK ND 58506- 5507
JOB SERVICE NORTH DAKOTA
701-328-2814 OR 800-472-2952
UNEMPLOYMENT INSURANCE
FAX: 701-328-1882
TTY: Relay ND 800-366-6888
SFN 19622 (R. 5-08)
Employer Name
Employer Address 1
Employer Address 2
City
State
ZIP
If no wages were paid write none in Item 1, sign and return.
1. Total Wages Paid
CHECK HERE IF ADDRESS HAS CHANGED - CHANGE ADDRESS ABOVE
This Quarter
Account Number
Quarter Ending Due Date
Tax Rate
%
2. Indicate If:
New Owner's Name
Date Sold
A.
Business has been sold
Date Discontinued
Address
Business has been discontinued
B.
New FEIN
City
State
ZIP
FEIN has changed
C.
3. Employee's Social
4. Name of Employee
5.
Gross Wages Paid
6.
Number of Employees
Security Number
this Quarter
Listed (all pages)
7. 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
2nd Month
3rd Month
8. TOTAL WAGES
(USE ADDITIONAL SHEETS IF NECESSARY)
THIS PAGE
9.
Name of Person Completing Report
Telephone Number
I certify that this report is correct and no part of the contribution was or will be paid by any employee.
Signature
Title
Telephone Number
Date
Job Service North Dakota is an equal opportunity employer/program provider.
Auxiliary aids and services are available on request to individuals with disabilities.
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