Instructions For Completing The Employer'S Contribution & Payroll Report - Iowa Workforce Development (Sample Form Included) Page 5
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5Employer's Contribution & Payroll Report
65-5300 (2000)
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12. Page ____________ of _____________
Iowa Workforce Development - 1000 East Grand Avenue
I
O
W
A
Des Moines, Iowa 50319-0209
Telephone (515) 281-5339
®
Payment Computation
(If no wages this quarter, see instructions)
1. Total Wages (All Pages) ..................................... $ _______________________
30000.00
13.
Iowa Account Number
For Months Of
Qtr Yr
123456-7
Jul-Aug-Sep
3-00
21000.00
2. Taxable Wages (All Pages) ................................ $ _______________________
3. Contribution Due
Year
Taxable Wage Base
Contribution Rate
Surcharge Rate
0.0100
210.00
(Item 2 X
) ............................... $ _______________________
2000 $17,300
1.00%
0.05%
4. Surcharge Due
Federal ID Number
Delinquent After Date
0.0005
(Item 2 X
) ............................... $ _______________________
10.50
01-2345678
10-31-00
220.50
5. Total lines 3 and 4 ............................................... $ _______________________
Employer Name & Address
6. Interest Due (See Instructions) ........................... $ _______________________
0.00
0.00
7. Penalty Due (See Instructions) ........................... $ _______________________
IOWA PUBLISHING HOUSE
220.50
8. Total Due (Items 5, 6 and 7) .............................. $ _______________________
110 WRITER ROAD
9. Amount Due from Previous Quarter .................... $ _______________________
0.00
PHEASANTVILLE, IOWA
50225-XXXX
0.00
10. Credit Due from Previous Quarter ...................... $ _______________________
11. Amount Paid. ..................................................... $ _______________________
220.50
(Make check payable to Iowa Workforce Development)
If total due is less than $1.00, no payment is required.
Payroll Listing
14.
Check if payroll reporting is by:
magnetic tape
cartridge
diskette
17. Total Wages Paid
18. Taxable Wages Paid
15. Social Security Number
16. Last Name
First Name
MI
.
444-61-5195
Robins,
Sue
A.
2500
00
2500
00
.
549-58-6111
Smith,
John
T.
6000
00
0
00
.
862-32-4177
Barns,
Ted
S.
18000
00
17300
00
.
909-44-9099
Paulmeno, May
K.
3500
00
1200
00
.
.
.
.
.
0.
1.
19. Totals For This Page
30000
00
21000
00
Labor Market Information
DEPARTMENTAL USE ONLY
20. Enter number of employees
21. For each month, report the number of covered workers who
1st Month
2nd Month
3rd Month
Do not write in shaded area.
paid wages
worked during or received pay for the payroll period which
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this quarter.
includes the 12th of the month
23. Amount of pay which exceeds regular and recurring payments to employees;
22. Identify Iowa Worksites
such as bonus, executive pay, severance pay, etc.,
. . . . . . . . . . . . . . . . . . . $
4000.00
Single Worksite
6 3
24. If the number of employees increased or decreased
County Number
1.
seasonal change
3.
layoff
5.
worksite opening
during the quarter for any of the following reasons,
please check the box(es) to indicate the reason(s).
X
2.
labor dispute
4.
recall
6.
worksite closing
For Multiple Worksites
Complete the "Multiple Worksite
If you have questions regarding Labor Market Information, please contact Research & Information
Report". If not received, please
Services at 1-800-532-1249 (in Iowa) or 1-515-281-8415 (outside Iowa).
call the telephone number at right.˙
F
E
C
R
FD
RTE
UNP
EC
CHG
LD
25.
If there are any CHANGES in your FEDERAL ID NUMBER, ACCOUNT NAME, ADDRESS, OR OWNERSHIP, please complete and return the "EMPLOYER'S NOTICE OF CHANGE".
I CERTIFY that this report is true and correct and that no part of the contribution was deducted from any employee's wages.
Print Preparer's Name
Preparer's Telephone Number
Mary L Johns
(515) 424-8665
Authorized Signature
Title
Office Manager
Business Telephone
Date
(515) 908-1046
October 28, 2000
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