Form C-31 Web - Wage Record Magnetic Media Application
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1Working Together for Vermont
Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Telephone:
802-828-4000
Montpelier, VT 05601-0488
Fax:
802-828-4022
TDD:
802-828-4203
Wage Record Magnetic Media Application
Name and address of your organization
Name ____________________________________
(Indicate where the tapes will be returned to)
Attn: _____________________________________
Street ____________________________________
City ______________________________________ State _________
Zip Code ____________
Name of contact person regarding this request
Name ____________________________________
Employer Account Number _______________
Telephone ________________________________
Federal ID Number _____________________
E-Mail Address ____________________________
Fax Number ______________________________
Indicate the Record Format Used (1, 2, 3, or 4)
1 = 3.5 Floppy or Compact Disc
2 = 80 BYTE
3 = 275 BYTE TIB-4
4 = 275 BYTE ICESA
Quarter ending date that data will be submitted on tape. __________
Estimated volume of Employee wage items per quarter. __________
PLEASE INDICATE:
Name, signature and title of person responsible for certifying accuracy of wage reports.
Name (Print or Type) _______________________________________
Date / Signature ___________________________________________
Title ____________________________________________________
Please mail or fax application to:
Vermont Department of Labor
Attn: Lucile Keene, Magnetic Media Specialist
P.O. Box 488
Montpelier, VT 05601-0488.
Faxed: 802-828-4286, Attention Lucile Keene.
C-31 WEB (9/05)
Equal Opportunity is the Law. Auxiliary aids and services are available upon request to individuals with disabilities.
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