Employer'S Contribution & Payroll Report - Iowa Workforce Development - 2003
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1
2Employer's Contribution & Payroll Report
65-5300 (2003)
12. Page __________ of _________
Iowa Workforce Development - Attn: Tax
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
Telephone (515) 281-5339
Payment Computation (If no wages this quarter, see instructions)
1. Total Wages (All Pages)...................... $ ____________________ 13.
Iowa Account Number
For Months Of
Qtr Yr
2. Taxable Wages (All Pages) ................. $ ____________________
Year
Taxable Wage Base
Contribution Rate
Surcharge Rate
3. Contribution Due
) ............... $ ____________________
(Item 2 X
Federal ID Number
Delinquent After Date
4. Surcharge Due
) ............... $ ____________________
(Item 2 X
5. Total lines 3 and 4 .............................. $ ____________________
Employer Name & Address
6. Interest Due (See Instructions)............. $ ____________________
7. Penalty Due (See Instructions)............. $ ____________________
8. Total Due (Items 5, 6 and 7) ............... $ ____________________
9. Amount Due from Previous Quarter ...... $ ____________________
10. Credit Due from Previous Quarter ....... $ ____________________
11. Amount Paid. ................................. $ ____________________
(Make check payable to Iowa Workforce Development)
If total due is less than $1.00, no payment is required; however, you are still required to file this
report with Iowa Workforce Development.
❒
❒
14.
Payroll Listing
Check if payroll reporting is by:
cartridge
diskette
16. Last
Name
First Name
MI
17. Total Wages Paid
15.
Social Security Number
18. Taxable Wages Paid
19. Totals For This Page
Labor Market Information
DEPARTMENTAL USE ONLY
20. Enter number of employees
21. For each month, report the number of covered workers
1st Month
2nd Month
3rd Month
Do not write in shaded area.
paid wages
who worked during or received pay for the payroll period
this quarter.
which includes the 12th of the month.
22.
Identify Iowa Worksites
23.
Amount of pay which exceeds regular and recurring payments to employees;
such as bonus, executive pay, severance pay, etc.,
. . . . . . . . . . . . . . . . . . .
$
Single Worksite
24.
If the number of employees increased or
County Number
1. ❒
3. ❒
5. ❒
seasonal change
layoff
worksite opening
decreased during the quarter for any of the
For Multiple Worksites
following reasons, please check the box(es)
2. ❒
4. ❒
6. ❒
labor dispute
recall
worksite closing
Complete the "Multiple Worksite
to indicate the reason(s).
Report".
If not received, please
If you have questions regarding Labor Market Information, please contact Employment Statistics
call the telephone
number at
Bureau at 1-800-532-1249 (in Iowa) or 1-515-281-8185 (outside Iowa).
right.
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25. If there are any CHANGES in your FEDERAL ID NUMBER, ACCOUNT NAME, ADDRESS, OR OWNERSHIP, please complete and return the "EMPLOYER'S NOTICE OF CHANGE".
I CERTIFY that this report is true and correct and that no part of the contribution was deducted from any employee's wages.
Print Preparer's Name
Preparer's Telephone Number
Authorized Signature
Title
Business Telephone
Date
This form is available at no cost to the public from Iowa Workforce Development.
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