Form Lb-0456 - Tennessee Department Of Labor And Workforce Development Premium Report
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1STATE ACCOUNT NUMBER
QTR/YEAR
QTR END DATE
DATE DUE
FEDERAL ID NUMBER
RATE
AREA
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
FOR OFFICE USE ONLY
DR
TC
If typed, disregard vertical bars and type a consecutive string of characters, without commas, hyphens, or dollar signs, left justified, with
decimal in monetary amount. For proper alignment, center Total Wages vertically within boxes and double space for each remaining line of
If handprinted, print your characters as shown below, within the boxes, right justified and without commas, hyphens, dollar signs, or
decilT1als.....
Follo~theE!xample~lllow ()fJ12~45.~7~9.00
to show
do.llars<l~~ c:E!l1t~.A'~a.y~.~~()~cel1ts.
123456789.00
I 2 3 It
5
,
7
,,
8 q
0·.··0·.·
Route
NW
CENTS
DOLLARS
FOR OFFICE
TOTAL WAGES
T
TN DEPT OF LABOR & WORKFORCE DEVELOPMENT
EMPLOYMENT SECURITY DIVISION
111111111111
EMPLOYER ACCOUNTS OPERATION
1000
P.O. BOX 101
NASHVILLE TN 37202-0101
(615) 741-2486
r
EMPLOYER
NAME AND
ADDRESS
L
.J
Show any address change above. See Reverse Side for Instructions.
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT PREMIUM REPORT
EMPLOYMENT SECURITY DIVISION I BUREAU OF UNEMPLOYMENT INSURANCE
data.
1.
2. LESS EXCESS WAGES
3. NET TAXABLE WAGES
(ITEM 1
minus
ITEM 2)
4. PREMIUM DUE
5.
INTEREST DUE
6. NO LONGER VALID
7.
NO LONGER VALID
8. PENALTY DUE
9. OUTSTANDING DEBIT
OR CREDIT
10.
TOTAL DUE
USE ONLY
LB-0456 (REV. 08-13)
1000
11. I certify that the information on this
report is true and correct.
Signature
_
Title
_
Date
_
Phone No........._ _-'-
_
FAX No.
Make check payable to:
Tennessee Department of
Labor and Workforce Development and mail
original reports (NO PHOTOCOPIES) to the
return address above.
RDA
2438
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