Form Oes-3-A - Employers Quarterly Contribution Report, Employers Quarterly Contribution Wage Report
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1
2AUXILIARY AIDS AND SERVICES ARE AVAILABLE UPON REQUEST TO INDIVIDUALS WITH DISABILITIES
EMPLOYERS QUARTERLY CONTRIBUTION REPORT
COMPUTATION OF PAYMENT DUE
IMPORTANT:
ONLY
INCLUDE INFORMATION FOR THIS QUARTER
TOTAL
TAXABLE
SOCIAL SECURITY
EMPLOYEE NAME
WAGES PAID
NUMBER
WAGES PAID
Total Wages (MUST EQUAL ITEM 5)
7.
000-00-0000
THIS QUARTER
THIS QUARTER
1.
2.
3.
4.
Taxable Wages (MUST EQUAL ITEM 6)
8.
Contribution Rate For This Quarter
9.
Contributions Due (Taxable Wages X Rate)
10.
Interest
11.
10% Penalty
12.
$100.00 Penalty
13.
Amount Due From Previous Quarters
14.
(Including Interest)
Credit Due From Previous Quarters
15.
Pay This Amount
16.
MAKE CHECK PAYABLE TO:
OKLAHOMA EMPLOYMENT SECURITY COMMISSION
17.
THE TAXABLE AMOUNT FOR
18. OKLAHOMA ACCT. NO.
19. QTR/YR
2004 is $ 14,300.00
2003 IS $ 11,700.00
2002 IS $ 10,500.00
20. FED. I.D. NO.
21. DATE DUE
22. TAPE/DISK
23. NUMBER OF EMPLOYEES
1ST MONTH
2ND MONTH
3RD MONTH
Total of All Pages
5.
6.
SUBMITTED
DURING THIS PERIOD
OKLAHOMA EMPLOYMENT
AMOUNT RECEIVED BY COMMISSION
SECURITY COMMISSION
WILL ROGERS MEMORIAL OFFICE BUILDING
DATE RECEIVED
BATCH NUMBER
PO Box 52004
OKLAHOMA CITY, OKLAHOMA
73152-2004
OES-3 (REV. 6-04) ORIGINAL - PLEASE SUBMIT
I HEREBY CERTIFY THIS REPORT IS CORRECT AND THAT NO PART OF THE CONTRIBUTION HAS BEEN OR WILL BE BORNE BY ANY EMPLOYEE. I UNDERSTAND ADDITIONAL PENALTIES MUST BE PAID FOR FAILURE TO REPORT AND
PAY CONTRIBUTIONS ON TIME.
SIGNATURE
TITLE
PHONE (
)
DATE
EQUAL OPPORTUNITY EMPLOYER / PROGRAM
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