Employer'S Mul Ti-Quarter Contribution And Payroll Report Form (Seasonal)

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MAINE DEPARTMENT
OF LABOR
BUREAU OF UNEMPLOYMENT
COMPENSATION
POST OFFICE BOX 259
AUGUSTA,
MAINE 04332-0259
Date Received
EMPLOYER'S MUL TI-QUARTER
CONTRIBUTION
AND PAYROLL REPORT
(SEASONAL)
Employer's
Name
Maine Employer
Account
No.
D/B/A Name
Federall.D.
No.
Address
9~!'-~~~dina
Quarter
Endina
Repol1the number of covered worj(ers who
worj(ed during or received pay lor the payroil
period which includes the 12th of the month.
II no employment in the payroll period, enter
zero.
Female
Total
OFFICE USE
ONLY
$
$
.TOTAL WAGES PAID
$
$
2.
LESS
EXCESS
WAGES
*
$
3.
NET TAXABLE
WAGES
$
YEAR 20
4.
CONTRIBUTION
DUE
$
$
5.
INTEREST
DUE
$
$
TAX RATE
6.
CONTRIBUTION
PENAlTY
DUE
$
$
$
$
ll,rAYRDLL
PENALTY
DUE
$
$
REMITTANCE
...MAKE
REMI1TANCE PAYABLE TO "BUREAU OF UNEMPLOYMENT COMPENSATION"~
I Qtr Ending:
I Nons~sonal
Qtr Ending:
{1)
Nonseasonal
EMPLOYEE.S
SOCIAL SECURITY NUMBER
NAME
OF EMPLOYEE
(Pj
Seasonal
(Pj
Seasonal
$
$
$
Additional
Space on Reverse
Totals This Page
$
$
$
Totals
For This
Return
$
$
$
$
certify
that the information
reported
herein
is true and correct.
Signature
Title
Telephone
No.
Date
* Wages
over
$12,000
paid to any employee
in one calendar
year. (To be deducted
only in the quarter
in
which
the excess
is paid.)
Me. C-2.6
(rev. 08/00)

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