Form 940-B - Request For Verification Of Credit Information Shown On Form 940
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1
2Department of the Treasury - Internal Revenue Service
940-B
Form
Request for Verification of
(Rev. May 2010)
Credit Information Shown on Form 940
Name and address of employer
Date
Calendar year
Employer identification number
The Form 940 filed with the IRS by the employer named above indicates the following information for the calendar year shown.
State Reporting No.
State in Which
Contributions
Experience Rate
as Shown on
Taxable Payroll
Experience
Employees Performed
Actually Paid
Period
Employer's State
(as defined in State Act)
Rate
to State
Services
(4)
Contribution Returns
(2)
(3)
(1)
(5)
(6)
From-
To-
State Agency: Please complete the certification below and fax or mail it back to us. Show any differences between the information shown above
and your records in the space below. Also show any contributions paid after February 1.
OR
Fax Number:
Mail to:
Other
(remarks, etc):
Director, Internal Revenue Service Center
Attention:
(FUTA Liaison)
State Reporting No.
Contributions
Experience Rate
Contributions
Contributions
as Shown on
Paid February 1
State Taxable
Experience
Period
Paid Before
Paid After
Employer's State
through
Wages
Rate
February 1
February 10
Contribution Returns
February 10
From-
To-
I certify that, except as shown above, the records of this office agree with the entries shown in columns (2), (3), (4), (5), and (6), and that all
contributions were paid before February 1.
Name of State
Name of State Officer
Date
Part 1-State Agency copy
Cat. No. 20910X
Form 940-B (Rev. 5-2010)
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