Form Fc-21 - Employer'S Quarterly Payroll Report
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1
2
3COMMONWEALTH of VIRGINIA
Virginia Employment Commission
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Employer’s Quarterly Payroll Report (FC-21)
File and pay your Unemployment Insurance tax online.
It’s fast, easy, accurate, and secure!
Employer
Name:
This Form Is Scanned.
Do Not Attempt To Amend or Make Account
Address 1:
Changes On This Form.
Address 2:
Write Legibly Within The Boxes
City:
A
B
1
C
2
3
_
Zip Code (Zip+4):
State:
Account
Federal ID
_
Quarter
/
/
Number:
Number:
Ending:
Social Security Number
Employee’s Name
Wages Paid in Quarter
_
_
,
,
.
M.I.
First
1.
Last
_
_
,
,
.
M.I.
First
2.
Last
_
_
,
,
.
M.I.
First
3.
Last
_
_
,
,
.
First
M.I.
4.
Last
_
_
,
,
.
First
M.I.
5.
Last
_
_
,
,
.
First
M.I.
6.
Last
Payroll Contact
Subtotal Wages Paid in Quarter
,
,
.
(Add Lines 1 – 6)
Print Preparer's Name and Title
Total Wages Paid in Quarter
,
,
.
(Add subtotal from all pages. Enter results here and
on Line 1 of Employer’s Quarterly Tax Report FC-20)
Preparer’s Phone Number / E-mail Address
Page
of
Equal Opportunity Employer/Program Auxiliary Aids and Services Are Available Upon Request to Individuals with Disabilities
Most services available at
(804) 786-4207
Print
Web-07-05-2012
T-FC-21
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