Form Uia 4101 - Employer'S Quarterly Tax Payment Coupon
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UIA 4101
Authorized By
(8-13)
MCL 421.1 et seq
S
M
TATE OF
ICHIGAN
RICK SNYDER
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
STEVE ARWOOD
GOVERNOR
LARA DIRECTOR
UNEMPLOYMENT INSURANCE AGENCY
P.O. Box 33598, Detroit, MI 48232-5598 – (855) 484-2636
SHAUN THOMAS
DIRECTOR
Employer’s Quarterly Tax Payment Coupon
Please use this payment transmittal ONLY when mailing your quarterly payment without
Form UIA 1028 (Employer’s Quarterly Wage/Tax Report).
Make your check/money order payable to: Unemployment Insurance Agency (UIA).
In order to ensure your account is properly credited, please include your 10-digit UIA
Employer Account Number on your check or money order. In order to avoid penalties
and interest, your tax return and payment must be received by the following due dates:
st
th
1
Quarter (January – March)
Due April 25
nd
th
2
Quarter (April – June)
Due July 25
rd
th
3
Quarter (July – September)
Due October 25
th
th
4
Quarter (October – December)
Due January 25
Complete the section below and mail this entire form along with your payment to the
address above.
Employer Name:
___________________________________
Federal Employer ID Number:
___ ___- ___ ___ ___ ___ ___ ___ ___
UIA Employer Account No:
___ ___ ___ ___ ___ ___ ___- ___ ___ ___
Quarter End Date [MM/DD/YYYY]: ___ ___ ___ ___ ___ ___ ___ ___
Payment Amount Enclosed:
$__________________________________
For UIA Use Only. Do Not Write Below Line.
LARA is an equal opportunity employer
Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
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