Form C-101 - Employer'S Quarterly Wage & Contribution Report With Instructions - 2001 Page 5
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5Vermont Department of Employment & Training
EMPLOYER'S QUARTERLY WAGE
P.O. Box 488
& CONTRIBUTION REPORT
Montpelier, Vermont 05601-0488
Employer's Copy
DO NOT MAIL
EMPLOYER NUMBER
EMPLOYER NAME
This is provided for your
Q-YR
use as a worksheet
Employer's Copy
QUARTER ENDING
DO NOT MAIL
DUE DATE
EMPLOYEE WAGE DATA FOR THIS QUARTER (Please type or print entries in BLUE or BLACK INK only)
1. SOCIAL SECURITY
3. TOTAL GROSS WAGES
5. HOURLY
6. GENDER
2. EMPLOYEE'S NAME (Last, First, Middle Initial)
4. H/S
NUMBER
PAID THIS QUARTER
RATE
M - F
TOTAL WAGES
THIS PAGE
C-101 (10/01)
7. PAGE 1 of _____PAGE
8. For each month, report the number of covered
1ST MONTH TOTAL
2ND MONTH TOTAL
3RD MONTH TOTAL
3RD MONTH FEMALE ONLY
workers who worked during or received pay for the
C-101 (10/01)
payroll period which includes the 12th of the month.
EMPLOYER NUMBER
9. Total Gross Wages Paid to all Subject Employees This Quarter
EMPLOYER NAME
10. Portion of Quarterly Wages from item 9 IN EXCESS of
Calendar Year Limit per Employee of
Q-YR
11. Taxable Wages - Subtract item 10 from item 9
QUARTER ENDING
12. Contribution Tax Due (item 11) Times Your Rate of
DUE DATE
13. Credit Adjustment (Subject to change - See Instructions)
14. TOTAL (Line 12 minus Line 13) If amount is negative, enter 0.
Payable to: VERMONT DEPT OF EMPLOYMENT & TRAINING
o No longer have employees in Vermont
16. DATE
17. TELEPHONE
DEPARTMENT USE ONLY
15.
o
Discontinued business in Vermont
18. SIGNATURE & TITLE (Must be owner, principal officer ot authorized representative)
o
Ownership or name as shown has changed.
I certify that I have complied with the requirements of 21 V.S.A. Section 687 relating to securing workers' compensation coverage for my employees and the
information contained in this report and all attachments is correct to the best of my knowledge.
Employer's Copy
DO NOT MAIL
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