Form Uc-55 - Employer'S Status Report - Commonwealth Of Pennsylvania Department Of Labor & Industry

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EMPLOYER’S STATUS REPORT
EMPLOYER’S NAME _________________________________________________________________
FOR EMPLOYEES WHOSE TOTAL SERVICES ARE PERFORMED
ADDRESS _________________________________________________________________________
WITHOUT, OR BOTH WITHIN AND WITHOUT PENNSYLVANIA
PA UC ACCOUNT NUMBER
(SEE INSTRUCTIONS ON REVERSE SIDE)
1
2
3
4
5
6
SPECIFY THE YEARS AND
EMPLOYEE’S NAME, SOCIAL SECURITY NUMBER,
LIST THE STATE IN WHICH
LIST THE STATE FROM
LIST THE STATE IN WHICH
LIST THE NAMES OF ALL
APPROXIMATE NUMBER OF
AND
EMPLOYEE’S BASE OF
WHICH EMPLOYEE’S WORK
YOU REPORTED AND PAID
STATES
WEEKS
RESIDENCE
OPERATIONS IS LOCATED
IS CONTROLLED
CONTRIBUTIONS ON
IN WHICH THE EMPLOYEE
IN WHICH SERVICES WERE
EMPLOYEE’S WAGES
PERFORMED SERVICES
PERFORMED IN EACH STATE
LISTED IN COLUMNS
YEARS
WEEKS
UC-55 REV 6-05 (Page 1)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES

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