Form Uc-B6 - Quarterly Wage, Contribution And Employment And Training Assessment Report
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1
2S T A T E O F H A W A I I
DO NOT WRITE IN THIS SPACE
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
UNEMPLOYMENT INSURANCE
DIVISION
QUARTERLY WAGE, CONTRIBUTION AND
EMPLOYMENT AND TRAINING A S S E S S M E N T R E P O R T
TAX OFFICE RECEIVED DATE
FEDERAL LD. NUMBER
ACCOUNT
NUMBER
FOR
QUARTERENDING
DELINQUENTAFTER
1) EMPLOYEE'S SSA #
2) EMPLOYEE'S NAME (LAST, FIRST)
3) TOTAL QTR WAGES PAlD
J
S T A T E T A X C O L L E C T O R
MAIL OR D E L I V E R R E P O R T S A N D R E M I T T A N C E S TO:
P.O. Box 3 2 2 3 , Honolulu, H a w a i i 9 6 8 0 1
4)
TOTALWAGES
OR
ON THIS PAGE
8 3 0 P u n c h b o w l S t r e e t
CONTRIBUTION
EMPLOYMENT & TNG
Honolulu, HI 9 6 8 1 3
[
RATE
ASSESSMENT RATE
"~
5) TOTAL FROM
OTHER PAGES
TOTAL WAGES PAID THIS QUARTER
6)
(sum of items 4 and 5)
17) NUMBER OF COVERED WORKERS
IN THE PAY PERIOD INCLUDING
7)
LESS WAGES PAID THIS QUARTER to Each
THE 12TH DAY OF EACH MONTH
Employee in Excess of Year's First
$
1ST MONTH
2NDMONTH
3RD MONTH
8)
NET TAXABLE WAGES
(subtract item 7 from item 6)
CONTRIBUTIONS DUE
9)
(multiply item 8 by
>>>>
•
I CERTIFY THAT THE INFORMATION ON THIS REPORT IS TRUE AND CORRECT.
10) E & T ASSESSMENT DUE
(multiply item 8 by
>>>>
AMOUNT DUE
SIGNED BY:
11)
(SUM OF ITEM 9 AND 10)
PRINT NAME:
12) OVERPAYMENT
(enter NOTIFICATION OF CREDIT amount)
ADJUSTED CONTRIBUTIONS DUE
TITLE:.
13) (subtract item 12 from item 11)
TELEPHONENUMBER:.
14) PENALTY AND INTEREST
DATE:
15) TOTAL PAYMENT DUE
(sum of items 13 and 14)
TOTAL REMITi-ANCE - PAY IN US DOLLARS ONLY
16) MAKE CHECK PAYABLE TO: HAWAII STATE TAX COLLECTOR
RETURN ORIGINAL FORM WITH PAYMENT
PLEASE INDICATE YOUR U.I. ACCT. NUMBER ON CHECK
FORM UC-B6 (REV. 12103)
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(ICSD L2BW)
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