MISSOURI

Missouri Department of Labor and Industrial Relations

DIVISION OF EMPLOYMENT SECURITY QUARTERLY CONTRIBUTION AND WAGE REPORT
PLEASE TYPE OR PRINT THIS REPORT
1. EMPLOYER NAME AND ADDRESS

2. MISSOURI EMPLOYER ACCOUNT NO.

AUDIT BLOCK (DO NOT USE) Date Paid

3. CALENDAR QUARTER

XYN
4. TOTAL WAGES PAID 5. WAGES PAID IN EXCESS OF PER WORKER PER YEAR 6. TAXABLE WAGES Item 4 Minus Item 5 7. CONTRIBUTIONS DUE Multiply Item 6 by Your RATE 8. INTEREST ASSESSMENT DUE TO FEDERAL ADVANCES

Due

$0.00
Pd Over Under

15. FEDERAL ID NUMBER

RETURN THIS PAGE WITH REMITTANCE TO: DIVISION OF EMPLOYMENT SECURITY PO BOX 888 JEFFERSON CITY MO 65102-0888
(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) THIS REPORT IS DUE BY
GREATER OF 10% OR $100 PENALTY AFTER GREATER OF 20% OR $200 PENALTY AFTER

9. INTEREST CHARGES PER MONTH If Paid After 10. LATE REPORT PENALTY CHARGES A. Greater of 10% or $100 B. Greater of 20% or $200 11. OUTSTANDING AMOUNTS AS OF 12. ADJUSTMENT TO PRIOR QUARTERS A. Underpayments B. Overpayments 13. TOTAL PAYMENT

$0.00

Adj/Cr. Applied

Place X in applicable box and complete "Report on Change of Business Operations" on the reverse side of the instruction sheet.

We have sold our business. We have ceased employment. We have an address change.
Please Print NAME TITLE

$0.00

14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH

1st
PHONE

2nd

3rd

S T A P L E C H E C K H E R E

SS NO.

NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER SIGNATURE ADDRESS PHONE

I certify that the information contained in this report, including name and address in Item 1 is true and correct.
First Initial Middle Initial

16. Social Security Number

17. Worker Name (Last Name)

18. Total Wages Paid This Quarter

19. Probationary

20. PAGE

1

OF

PAGES

TOTAL THIS PAGE

$0.00

MODES-4-7 (10-07) AI

IHE

OF

PAGES

THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

MISSOURI
Missouri Department of Labor and Industrial Relations

DIVISION OF EMPLOYMENT SECURITY QUARTERLY CONTRIBUTION AND WAGE REPORT
PLEASE TYPE OR PRINT THIS REPORT
1. EMPLOYER NAME AND ADDRESS

2. MISSOURI EMPLOYER ACCOUNT NO.

0
3. CALENDAR QUARTER

XYN
4. TOTAL WAGES PAID

0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0 .00000 0
EMPLOYER'S COPY RETURN ORIGINAL WITH ANY REMITTANCE DUE

0 0 0 0 0 0 0

5. WAGES PAID IN EXCESS OF

PER WORKER PER YEAR 6. TAXABLE WAGES Item 4 Minus Item 5 7. CONTRIBUTIONS DUE Multiply Item 6 by Your RATE 8. INTEREST ASSESSMENT DUE TO FEDERAL ADVANCES 9. INTEREST CHARGES PER MONTH If Paid After

.00000

15. FEDERAL ID NUMBER

0

RETURN THIS PAGE WITH REMITTANCE TO: DIVISION OF EMPLOYMENT SECURITY PO BOX 888 JEFFERSON CITY MO 65102-0888
(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) THIS REPORT IS DUE BY
GREATER OF 10% OR $100 PENALTY AFTER GREATER OF 20% OR $200 PENALTY AFTER

$0.00

10. LATE REPORT PENALTY CHARGES A. Greater of 10% or $100 B. Greater of 20% or $200 11. OUTSTANDING AMOUNTS AS

$0.00
RETAIN FOR YOUR RECORDS

0 0 0

OF 12. ADJUSTMENT TO PRIOR QUARTERS A. Underpayments B. Overpayments 13. TOTAL PAYMENT

0

$0.00

Place X in applicable box and complete "Report on Change of Business Operations" on the reverse side of the instruction sheet.

$0.00

0 0 0
Please Print NAME TITLE

We have sold our business. We have ceased employment. We have an address change.

$0.00

0 0 0PHONE 0

14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH

1st 0

2nd 0

3rd

0
0 0

S T A P L E C H E C K H E R E

SS NO.

NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER SIGNATURE ADDRESS

I certify that the information contained in this report, including name and address in Item 1 is true and correct.

0 PHONE

16. Social Security Number

First Initial

Middle Initial

17. Worker Name (Last Name)

18. Total Wages Paid This Quarter

19. Probationary

0 0 0 0 0 0 0 0 0
20. PAGE

0 0 0 0 0 0 0 0 0
1
OF

0 0 0 0 0 0 0 0 0
0

0 0 0 0 0 0 0 0 0
PAGES

0 0 0 0 0 0 0 0 0
TOTAL THIS PAGE

0 0 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0 0 0 0 0 0 0 0 0
MODES-4-9 (10-07) AI

IHE

OF

PAGES

THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF EMPLOYMENT SECURITY

Missouri Quarterly Wage Report CONTINUATION SHEET
Print in this space employer's name and account number as shown on Form MODES-4 Missouri Quarterly Contribution and Wage Report Calendar Quarter/Year

P.O. Box 888 Jefferson City, MO 65102-0888

0 0
16. Social Security Number First Initial Middle Initial 17. Worker Name (Last Name)

Type or print in ink

18. Total Wages Paid This Quarter

19. Probationary

20. PAGE

2

OF

0

PAGES

TOTAL THIS PAGE

$0.00

Be sure that each page carries employer's name, account number, page number and calendar quarter and year. Return the original completed form to the Division of Employment Security, P.O. Box 888, Jefferson City, MO 65102-0888. Retain copy for your file.

MODES-10B (12-99) AI Cont.