Form Wyo 065 - Payment Coupon Form - State Of Wyoming

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Payment Coupon
WYO 065
07 / 01 / 05
●
Business Name
Check #
Quarter/Year
WC Employer #
WC Amount
WC Amount
Due $
Paid $
-
-
Total Amount
Check Amount $
Due $
State Use Only
Date Received
Payment Type
Initials
Postmark
Date
●
Return to:
Wyoming Department of Employment
Workers' Safety & Compensation
Employer Services
P O Box 20006
from internet
Cheyenne WY 82003
FISCAL

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