Form Esd-Ark-209c -Employer'S Quarterly Contribution And Wage Report - 1990
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1
2SIC
AUD
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EMPLOYER'S QUARTERLY CONTRIBUTION AND WAGE REPORT
ARKANSAS EMPLOYMENT SECURITY DEPARTMENT
P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3798
ESD ID NUMBER
DATE QUARTER ENDED
FEDERAL ID NUMBER
Check box and return if no wages paid
PART A.
1st mo
2nd mo
3rd mo
of qtr______ of qtr ______ of qtr ______
1. Number of employees in the pay period including the 12th of:
$
.
2. Total of all wages paid for personal services, including bonuses/commissions......
$<
.
>
3. Wages in excess of $
(see instructions)....................................
$
.
4. Taxable wages (subtract item 3 from item 2, enter results here)...................
5. Contribution rate for this reporting period........................................
$
.
6. Contribution due for this quarter (multiply item 4 by
)....................
$
7. Amount due from previous quarters.......as of
...excludes interest..
$
8. Amount of credit from previous quarters...as of
....................
$
.
9. Interest (accrued on all unpaid contributions at the rate of 1.5% per month)......
$
.
10. Penalty (see instructions)........................................................
$
.
11. Total amount due..................................................................
$
.
12. Amount of remittance (make payable to Arkansas Employment Security Department)....
CASHIER'S STAMP
DO NOT ALTER OR REPRODUCE THIS BARCODED FORM
Initial
PART B.
Amt received
Enter the SSN, first name, middle initial, last name and
total wages paid to each employee during the calendar
quarter in the space provided below (continuation sheet
Penalty code
printed on reverse side).
SOCIAL SECURITY NUMBER
FIRST NAME, MIDDLE INITIAL & LAST NAME OF EMPLOYEE
TOTAL WAGES PAID
$
.
1]
$
.
2]
$
.
3]
$
.
4]
$
.
5]
$
.
6]
$
.
7]
$
.
8]
$
.
PAGE ONE OF _______ PAGE(S)
TOTAL NO. OF EMPLOYEES
TOTAL WAGES FOR THIS PAGE
ON THIS REPORT _______
I HEREBY CERTIFY THIS REPORT IS TRUE AND CORRECT AND NO PARTS OF THE CONTRIBUTION HAVE OR WILL BE BORNE BY
ANY EMPLOYEE.
SIGNATURE ___________________ TITLE _______________ DATE ________ TELEPHONE ___________
ESD-ARK-209B
(REV. 01-02)
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