Form Sfn 41253 - Employer'S Contribution And Wage Report
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1EMPLOYER'S CONTRIBUTION AND WAGE REPORT
UNEMPLOYMENT INSURANCE
JOB SERVICE NORTH DAKOTA
UI/TAX & FIELD SERVICES
SFN 41263 (R. 2-12)
PO BOX 5507 BISMARCK ND 58506-5507
701-328-2814
TTY: RELAY ND 800-366-6888 FAX: 701-328-1882
Taxable wages in 2012 are the first $27,900 paid
each employee in the calendar year. If no wages were
paid write none in item 1, sign and return.
1. Total Wages Paid
This Quarter
Employer Name
Employer Name
2. Excess Wages
Employer Address 1
Employer Address 1
3. Taxable Wages
(line 1 minus line 2)
Employer Address 2
Employer Address 2
4. Contribution Due
x Line 3
City
City
State
State
ZIP
ZIP
Adjustments for
5
Prior Balance
6. Penalty
CHECK HERE IF ADDRESS HAS CHANGED - CHANGE ADDRESS ABOVE
CHECK HERE IF ADDRESS HAS CHANGED - CHANGE ADDRESS ABOVE
Account Number
Quarter Ending
Due Date
Tax Rate
Tax Rate
7. Interest
8. Total Amount Payable to
%
%
Job Service North Dakota
9. Indicate If:
Date Sold
New Owner's Name
A.
Business has been sold
Date Discontinued
Address
Business has been discontinued
B.
New FEIN
City
State
ZIP
C.
FEIN has changed
10. Employee's Social
11. Name of Employee
12. Gross Wages Paid
13. Number of Employees
Security Number
this Quarter
Listed (all pages)
14. For each month, report the
number of covered workers who
worked during or received pay for
the payroll period which includes
the 12th of the month.
1st Month
2nd Month
3rd Month
15. TOTAL WAGES
(USE ADDITIONAL SHEETS IF NECESSARY)
THIS PAGE
16. Name of Person Completing Report
Telephone Number
I certify that this report is correct and no part of the contribution was or will be paid by any employee.
Signature
Title
Telephone Number
Date
Job Service North Dakota is an equal opportunity employer/program provider.
Auxiliary aids and services are available on request to individuals with disabilities.
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Parent category: Financial