Form Et 5351 PDF Details

Et 5351 is an important tax form for individuals and businesses who have made or received taxable payments in a specific year. The form is used to report certain types of payments, including interest, dividends, rents, royalties, annuities, and other types of taxable income. It's important to understand how to complete the form and submit it on time so that you can avoid penalties and taxes owed. This blog post will provide an overview of Et 5351 and explain how to complete it correctly. Stay tuned for future posts that will provide more detailed instructions on specific sections of the form. Thanks for reading!

Form NameForm Et 5351
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameset5351 wt7 form

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Department of Employee Trust Funds (ETF)



Wis. Stat. § 40.61 and 40.62


Employee Name

Social Security Number

Employer Identification Number

The employee named below is applying for an ICI benefit. Please follow

the detailed instructions on the back of this form and return it to the Department of Employee Trust Funds (ETF) promptly. Benefits cannot be computed until this form is received and processed.

Occupation (Title)






Previous Calendar Years Salary


Last Day Worked




Last Day Paid


Seasonal/Academic Yr


















Projected Salary:





























































New Hire





























Per Diem


































Change in Appointment

































































Change in Hourly Rate*























Monthly Salary


Full Time





Has claim been filed for

Worker’s Comp. Effective

Weekly Worker’s






Part Time





Worker’s Comp?













Comp Amount






































Part Time Percent





Paid Thru































































































































(State Only) Total Sick Leave Shown to hundredths of


(State Only) Date Sick Leave is

Premium Category/Elimination Period

an hour–2 Decimal Places





Exhausted (MM/DD/CCYY)




































Current Year

Accumulated Hrs


















































Earned Hours

































































































Total Hours





































































































(UW-Faculty Only)

Elimination Period- Calendar Days





(Locals Only)

Elimination Period-Calendar Days

30 60 90 120 180

Premiums are Paid Through (MM/DD/CCYY)

(Locals Only) Percentage of Premium Paid by Employer in Prior Years:











Current Year






























Claimant has elected the supplemental ICI Coverage.






(State Only) Claimant Has Elected To: Use a Max. of 130 Days of Sick Leave

Bank All Sick Leave After:




Division (STATE)

Central Payroll Code Number (STATE)

I understand Wis. Stat. § 943.395 provides penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the above information is true and correct.


Authorized Employer Signature

Employer contact e-mail address:

Employer Telephone No.


Date Sent to Employer:

Sent by:

Telephone Number:

ET-5351 (REV 02/2011) Mail to: ETF, PO BOX 7931, MADISON 53707-7931

FAX: (608)267-4549

Employer Instructions

1.Complete this form as quickly as possible and e-mail to this address: If you are unable to e-mail it please fax to ETF at (608)267-4549 OR send it by mail to the address on page 1. No ICI benefits are payable to your employee until the completed form (and required medical) is received and processed.

2.For State or Local employees, report the last day paid for any vacation, holiday or compensatory time paid after the elimination period. For Local employees only, report last day paid for any sick leave paid in addition to any vacation, holiday or compensatory time paid after the elimination period.

3.Monthly Salary –

To determine benefits as of the date of disability, the average monthly salary is determined by using the:

Previous calendar year salary, rounded to the next higher thousand and divide by 12.


If there is a new hire or a permanent change in appointment, estimate the base salary (including add-ons for certain educational degrees, certifications, licenses or credentials) to be received during the ensuing 12 months. Round to the next higher thousand and divide by 12.

* NOTE: If the employee has received a permanent change in the hourly rate (and is not a new hire or did not have a change in appointment), report the higher of:

Previous calendar year salary. OR

Projected salary.

4.For State employees, report the accumulated sick leave hours as of the employee’s last day worked, plus any additional sick leave earned while continuing in pay status. Report sick leave in hours and hundredths of hours (2 decimal places), not minutes.

5.For most State employees who work a standard Monday – Friday work week, sick leave is not utilized on paid legal holidays and thus extends the date sick leave is exhausted.

6.For State employees, an ICI claimant who has applied for a Wisconsin Retirement System disability, Long Term Disability Insurance (LTDI) benefit, or duty disability benefit may convert (bank) sick leave to pay for health insurance premiums and begin ICI benefits at an earlier date. Determine, with the employee, the date through which sick leave is to be used. If the permanent disability is not approved, the date through which sick leave was used will have to be adjusted. Attach written documentation to this form, which verifies the employee’s decision to bank sick leave after a specified date.

7.Continue to collect premiums, for eligible employees, until you receive written notice of approval of the claim. Note that no premiums can be accepted after employment is terminated.

8.Under “Premium Category,” fill in the premium category or selected elimination period for the year in which the disability began (current year) as well as the previous three calendar years.

9.Indicate whether the employee is enrolled in the supplemental ICI coverage.

10.After completion, please make a copy of this form for your records for future reference.

11.Please include your e-mail address.

ET-5351 (REV 02/2011)