Read DWS-ARK-209B%20Interactive.pdf text version

NAICS

AUD

CO

EMPLOYER'S QUARTERLY CONTRIBUTION AND WAGE REPORT ARKANSAS DEPARTMENT OF WORKFORCE SERVICES

P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007 (501) 682-3798

DWS ID NUMBER DATE QUARTER ENDED FEDERAL ID NUMBER REPORT DUE DATE Check box and return if no wages paid c

PART A.

1. 2. 3. 4. 5. 6. 7. 8. 9. 0. 1 1. 1 12.

1st mo

2nd mo

3rd mo

Numberofemployeesinthepayperiodincludingthe12thof: ofqtr_________ ofqtr_________ ofqtr_______ Totalofallwagespaidforpersonalservices,includingbonuses/commissions............... $ ______________.____ _ Wagesinexcessof (seeinstructions) .............................................................. $<_______________.____ . Outofstatewagesifemployee(s)arepaidinmultiplestates(seeinstructions)........... $<_______________.____ Taxablewages(subtractitem3and4fromitem2,enterresultshere)........................... $________________.____ Contributionrateforthisreportingperiod ......................................................................... ____________________ . Contributiondueforthisquarter(multiplyitem5by ).......................................... $________________.____ Amountofdebitorcreditfrompreviousquarters............................................................. $________________.____ Interest(accruedonallunpaidcontributionsattherateof1.5%permonth)................ $________________.____ Penalty(seeinstructions)..................................................................................................... $________________.____ Totalamountdue................................................................................................................. $________________.____ Amountofremittance(makepayabletoArkansasDepartmentofWorkforceServices)........ $________________.____

DO NOT ALTER THIS FORM PART B.

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 provided).

SOCIAL SECURITY NUMBER

CASHIER'S STAMP

Initial

Amt received

FIRST NAME, MIDDLE INITIAL & LAST NAME OF EMPLOYEE

TOTAL WAGES PAID

1)

ATTACH CHECK HERE

2) 3) 4) 5) 6) 7) 8)

PAGE ONE OF _______ PAGE(S) TOTAL NO. OF EMPLOYEES ON THIS REPORT __________ TOTAL WAGES FOR THIS PAGE

$ $ $ $ $ $ $ $ $

. . . . . . . . .

I HEREBY CERTIFY THIS REPORT IS TRUE AND CORRECT AND NO PARTS OF THE CONTRIBUTION HAVE OR WILL BE BORNE BY ANY EMPLOYEE. SIGNATURE ______________________________TITLE __________________________ DATE _______________ TELEPHONE __________________

DWS-ARK-209B (REV.01-09)

MAINTAIN COPY FOR YOUR RECORDS

CONTINUATION SHEET FOR FORM 209B

DWS ID Number ___________________________________ Town _________________________________________ Quarter End Date _____________________ Page ________ of ________ Employer ____________________________________________________________

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 ) 13 ) 14 ) 15 ) 16 ) 17 ) 18 ) 19 ) 20 ) 21 ) 22 ) 23 ) 24 ) 25 ) 26 )

TOTAL WAGES FOR THIS PAGE

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

. . . . . . . . . . . . . . . . . . . . . . . . . . .

DWS-ARK-209C (REV. 06-06)

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