Form Esd-Ark-209br - Employer'S Quarterly Contribution And Wage Report - 1990
ADVERTISEMENT
1
2SIC
AUD CO
EMPLOYER'S QUARTERLY CONTRIBUTION AND WAGE REPORT
ARKANSAS EMPLOYMENT SECURITY DEPARTMENT
P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3278
REIMBURSABLE
ESD ID NUMBER ______________________
DATE QUARTER ENDED ______________
FEDERAL ID NUMBER ________________
REPORT DUE DATE __________________
PART A.
1st mo.
2nd mo.
3rd mo.
1. Number of employees in the pay period including the 12th of: of qtr ________ of qtr ________ of qtr _________
2. Total of all wages paid for personal services, including bonuses/commissions……………….. $ __________.____
3. Penalty (see instructions) ……………………………………………………………………..
$ __________.____
4. Amount of remittance (make payable to Arkansas Employment Security Department) …….
$ __________.____
DO NOT ALTER OR REPRODUCE THIS BARCODED FORM
Initial
Amt. Received
PART B.
Penalty Code
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 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)
_____
______
_____
______________________
________________
_______________________
$ _______________ . _____
9)
_____
______
_____
______________________
________________
_______________________
$ _______________ . _____
10)
_____
______
_____
______________________
________________
_______________________
$ _______________ . _____
11)
_____
______
_____
______________________
________________
_______________________
$ _______________ . _____
12)
_____
______
_____
______________________
________________
_______________________
$ _______________ . _____
Total No. of Employees on
Page
One of
______
Page(s)
Total Wages for this page
this report ___________
$ _______________ . _____
I hereby certify this report is true and correct.
SIGNATURE _____________________ TITLE ____________________
DATE __________ TELEPHONE ______________
ESD-ARK-209BR
(REV. 10-90)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial