Form 1 - Quaterly Contribution Report - 2005
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4DEPARTMENT OF WORKFORCE DEVELOPMENT
First Quarter 2005
051
DIVISION OF UNEMPLOYMENT ASSISTANCE
Contribution Report
BUSINESS NAME & ADDRESS
DUA Account #
Federal ID #
Due Date:
April 30, 2005
File your report even when you owe nothing.
12% interest is charged for late payments.
Other penalties may apply for late filings.
Use Black or Blue Ink ONLY!
File online at https://wfb.dor.state.ma.us/Webfile
For each month during the quarter enter the number of covered
January
February
March
Employee
employees who worked during
OR
received pay for the payroll
Count
period which includes the 12th day of the month. If none, enter 0.
Round to nearest whole dollar
Quarterly
A.
Enter Total Gross Wages Paid this quarter.
A.
0 0
,
,
,
Contribution
B.
Enter wages paid this quarter in excess of
$14,000
B.
0 0
,
,
,
.
per employee this year.
(see explanation on reverse side)
B
A
C.
C.
Subtract
from
and enter amount in
C.
0 0
,
,
,
These are your Wages Subject to Contribution.
D.
C
D.
Multiply
by .0006 (.06%) and enter amount in
D.
0 0
,
,
,
.
This is your Workforce Training Fund Contribution.
C
E.
E.
.
Multiply
by
and enter amount in
E.
0 0
,
,
,
This is your Unemployment Insurance Contribution.
Quarterly
F.
The Previous Quarter Deferral Amount equals zero. The
000000.00
F.
Deferral
option to defer was not available in the previous quarter.
Option
G.
E
Multiply
by .34 (34%). This is your maximum deferral
(see reverse)
G.
amount. Enter "0" or any amount that does not exceed your
0 0
,
,
,
.
G.
maximum deferral amount in
Calculate
H.
0 0
H.
D
E
G
H.
,
,
,
Add
and
then subtract
and enter this amount in
Total
Payment Due
I.
This is your DUA Approved Credit amount.
. 0 0
I.
ð
I
H
J.
Total Payment Due
Subtract from
and enter your
J.
0 0
,
,
,
If is greater than
I
H
, enter zero.
I certify this report is true and correct. No part of contributions was deducted from any employee’s wages.
Sign
Signature:____________________________________ Title:_____________________ Phone: (____) _____-______ Date: ___________
and Certify
Type of Organization (check one):
Individual
Corporation
Estate
Partnership
Trust
Other: ______________
Do Not Staple your Check to this Form
1.
Make check payable to:
Return this
MA Division of Unemployment Assistance
form by
David Palmquist
2971
100 Elm Street
2.
DUA Account Number on the check
Write your
April 10, 2001
DATE
April 30, 2005
Boston, MA 02114
PAY TO THE
MA Division of Unemployment Assistance $ 100.00
3.
Mail check and Contribution Report to:
ORDER OF
DOLLARS
One Hundred and 00/100
File a report
Division of Unemployment Assistance
even when you
First State Bank
PO Box 3269
16-39076-9
owe nothing.
Boston, MA 02241-3269
Contact us at :
(617) 626-5243 or
Form 1 - Rev. 09/08/06
See reverse for further instructions:
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