Form Uct-5334 - Agricultural Employer'S Report - 2013 Page 2
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217. If you have any employees in any of the Excluded Categories below, check all that apply:
A sole proprietor's father, mother, spouse, or any of his/her children under the age of 18. Identify those claimed:
Father
Mother
Spouse
Child under 18 - Give Birthdate ____________
Child under 18 - Give Birthdate ____________
Child under 18 - Give Birthdate ____________
Unpaid corporate officers
Show gross cash wages
Complete the following record of your quarterly agricultural payroll in Wisconsin.
paid in each
18.
Do not
calendar quarter.
include wages for employees shown as excluded in question 17.
YEAR
1st QTR. JAN-MAR
2nd QTR. APR-JUNE
3rd QTR. JULY-SEPT
4th QTR. OCT-DEC
2011
2012
2013
Do you have employment outside of Wisconsin?
No
If yes, give number of those employees: ____
Yes
19.
20.
Are you liable for Federal Unemployment Tax on your agricultural payroll for the calendar years:
Yes
No
2011
Yes
No
2012
Yes
No
2013
Indicate whether you had 20 weeks in which at least 10 employees worked full or part-time on one or more days in
21.
agricultural labor (not counting employees working in excluded employment). If you answer yes, give the date the 20th
week ended.
Yes
No
2011
If yes, date: _____________
2012
Yes
No
If yes, date: _____________
2013
Yes
No
If yes, date: _____________
Section 108.24(2) provides for fines and/or imprisonment for making known false statements on this report or for
refusing to submit the completed report to this office.
Your signature below indicates the report is true and
complete to the best of your knowledge and belief.
Date Signed
Signature
(U00604) (R. 11/19/2012)
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