Instructions For Completing The Wyoming Quarterly Ui/wc And Ui Only Summary Report Form (Page 2 of 2) in pdf

To correct or file reports for a prior quarter call

Instructions

(307) 235-3217 or visit our website at:

for completing the Wyoming Employee Wage Listing

to obtain forms.

Do not enter more than 12 employees or 4

Corporate Officers per page. To obtain additional

ABC SAMPLE CO INC

1 2016

blank forms call (307) 235-3217.

111 SAMPLE RD

012345678

SAMPLE TOWN, US 111111

007654321

Substitute forms will not be accepted.

236115

123 45 6789

JONES SAM

1899 00

01 20 2016

236

236115

USE BLACK INK ONLY

223 45 6789

SMITH TOM

30 35

3543 45

294

*A1: Enter the Social Security Number of each

236115

323 45 6789

BROWN DON

7762 45

659

covered employee receiving wages during this quarter

236115

423 45 6789

SIMPSON ABLE

49 50

774 00

02 13 2016

*A2: Enter the Last and First Name of the employee

000010

identified by the Social Security Number in item A1

523 45 6789

SAMPLE TERRI

5000 00

200

A3: Enter the amount of tips each employee earned

during this quarter. NOTE: Tips are included as wages

for UI tax computations but not included as wages for

WC tax computations. Enter the Tips subtotal at the

bottom of this

column (A3)

*A4: Enter the total of all wages, excluding tips,

earned by each employee during this quarter. Enter the

subtotal of wages at the bottom of this column (A4a)

A5: Enter the NAICS/Class Code for each employee

79 85

18978 90

19058 75

as assigned by WC (see 9A of the Quarterly UI/WC

Summary report).

Required if filing both UI and WC on this

form

623 45 6789

SAMPLE JOE

11673 51

27680 00

647

236115C

*A6: Enter the appropriate type for each

723 45 6789

SAMPLE SALLY

15000 00

200

employee:

B if covered by both UI and WC

U if covered only by UI

11673 51

42680 00

61738 75

W if covered only by WC

A7: Enter the date of hire for each employee

hired during this quarter

CORPORATE OFFICER/LLC MEMBER INFORMATION

A8: Enter the hours each employee worked

A9: Enter the Workers’ Compensation Corporate Officer/LLC Member/Owner average wage only if Workers’

during this quarter, rounded to the nearest hour.

Compensation Corporate Officer/LLC Member/Owner coverage has been elected and a class code ending in the letter

Do not use fractions or decimals (Salary use 522 hrs.)

“C” has been assigned to the account (see 9A of the Quarterly UI/WC Summary report). Do not use actual wages in

*A3+A4a: Enter the subtotal of Tips and Wages

this field (to report actual wages see A4 instructions below). Enter the subtotal at the bottom of this column (A9).

for the employees

A4: Enter the actual wages, including tips, earned by each Corporate Officer (required for UI) or LLC Member

*A3+A4a+A4b: Enter the grand total of all

(optional for UI) during the quarter. Enter the subtotal at the bottom of this column (A4b)

employee and corporate officer wages

Workers Compensation Corporate Officer Average Wage for 2016 is $11,673.51

*Required Field

Instructions For Completing The Wyoming Quarterly Ui/wc And Ui Only Summary Report Form Page 2

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