Please review the following information about your unemployment insurance tax filing, and supply the number of employees on the 12th day of each month in the filing quarter.

NOTICE: Please update employee counts before adjusting excess wage totals or employee counts will be lost.

UI Tax Filing for

PRETEND COMPANY

Employer Account Number:

Year/Quarter: 

Number of Employees: 

You must supply the following: 
- Number of employees on 01/12/2003
- Number of employees on 02/12/2003
- Number of employees on 03/12/2003

Total Wages: 

Excess Wages: 

Taxable Wages: 

Tax Rate: 

Unemployment Insurance Tax: 

Late Payment Penalty: 

Interest Due: 

Balance Past Due: 

Total Amount Due: 

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