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S
M
TATE OF
ICHIGAN
RICK SNYDER
TALENT INVESTMENT AGENCY
STEPHANIE COMAI
GOVERNOR
DIRECTOR
UNEMPLOYMENT INSURANCE AGENCY
PO B
33598, D
, MI 48232-5598 – (855) 484-2636
OX
ETROIT
S
M
-M
, UIA
HARON
OFFETT
ASSEY
DIRECTOR
Employer’s Quarterly Tax Payment Coupon
Please use this payment transmittal ONLY when mailing your quarterly payment without Form
UIA 1028 (Employer’s Quarterly Wage/Tax Report).
Make your check/money order payable to: Unemployment Insurance Agency (UIA). In order
to ensure your account is properly credited, please include your 10-digit UIA Employer Account
Number on your check or money order. In order to avoid penalties and interest, your tax return
and payment must be received by the following due dates:
th
1st Quarter (January – March) Due April 25
2nd Quarter (April – June) Due July 25th
3rd Quarter (July – September) Due October 25th
4th Quarter (October – December) Due January 25th
Complete the section below and mail this entire form along with your payment to the address
above.
Employer Name: __
eral Employer ID Number: ________________________
Please enter the correct Employer Account Number
UIA Employer Account No: __________________________
Quarter End Date [MM/DD/YYYY]: _____________________
Payment Amount Enclosed: $ ________________________
For UIA Use Only. Do Not Write Below Line.
UIA 4101
(Rev. 10-14)
TIA is an equal opportunity employer/program.
Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.