Form Uc 30 – Fill Out and Use

FORM ID:

EMPLOYER'S QUARTERLY CONTRIBUTION

POSTMARK DATE

DOES-UC30

AND WAGE REPORT

(DO NOT USE THIS SPACE)

EMPLOYER NUMBER:

NAME CHK:

FEDERAL IDENTIFICATION NUMBER:

TAX RATE:

QUARTER ENDING:

TAXABLE WAGE BASE:

THIS REPORT DUE:

SEE INSTRUCTIONS ON PAGE 3

HERE

1st Month

2nd Month

3rd Month

1.

TOTAL NUMBER OF COVERED WORKERS (employed in Washington, DC.)

3.

NON-TAXABLE WAGES m m m

m m m m m

m m

m

m m m

m m m m m m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

$

2.

TOTAL WAGES PAID (this quarter, to all

covered workers) m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

$

ORDER

DO YOU SUBMIT YOUR WAGE DATA ON MAGNETIC MEDIA? m

m

m

m

m

m

m

YES

NO

MONEYORCHECK

RATED EMPLOYERS COMPLETE ITEMS 3 THROUGH 10 - SELF INSURED EMPLOYERS SKIP TO ITEM 11

7.

PLUS INTEREST DUE

m m m m

m m m m m

m m

m

m m m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

$

4.

TAXABLE WAGES (Subtract

ITEM 3 from ITEM 2)

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

$

8.

PLUS PENALTY DUE

m m m m

m m m m m

4

m m

m

m m m m m m m m m

m

m

m

m

m

m

m

m

m

$

5.

CONTRIBUTION DUE (Multiply ITEM

by your tax rate of

%)

m

m

m

m

m

$

9.

MINUS APPROVED CREDIT

m m m m m

m m

m

m m m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

$

6.

PLUS ADMIN. ASSESSMENT DUE (Multiply

ITEM

4 by two tenths of one percent (0.2%)

$

m

ATTACH

m

m

m

m

m

m

m

$

10.

EQUALS TOTAL REMITTANCE AMOUNT (Make check or money order payable to 'DOES')

STATUS CHANGES

11.

ENTER THE APPROPRIATE INFORMATION IF ANY CHANGE HAS OCCURRED:

ENTITY NAME:

TRADE NAME:

ADDRESS LINE 1:

ADDRESS LINE 2:

CITY:

STATE:

ZIP CODE:

CONTACT NAME:

CONTACT TELEPHONE:

BUSINESS TELEPHONE:

BUSINESS FAX:

EMAIL ADDRESS:

NEW FEIN:

12.

IF YOU HAVE SOLD OR TRANSFERRED YOUR BUSINESS, enter date of sale or transfer:

IF NO LONGER IN BUSINESS, enter date wages last paid in DC: m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

Month

Day

Year

Month

Day

Year

13.

DESCRIBE ANY OTHER CHANGE IN STATUS:

CERTIFICATION

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT AND ANY WAGE REPORTS ATTACHED HERETO IS TRUE

AND CORRECT AND THAT NO PART OF THE TAX WAS OR IS TO BE DEDUCTED FROM THE WORKER'S WAGES.

SIGNATURE:

TELEPHONE:

DATE:

PRINT NAME:

TITLE:

Page 1

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1062

Office of Unemployment Compensation P.O. Box 96664 Washington, D.C.

20090-6664 Telephone:

Local: (202) 698-7550 Toll Free: (877) 319-7346

FORM ID:

EMPLOYER'S QUARTERLY CONTRIBUTION

DOES-UC30

AND WAGE REPORT

EMPLOYER NUMBER:

NAME CHK:

FEDERAL IDENTIFICATION NUMBER:

TAX RATE:

QUARTER ENDING:

TAXABLE WAGE BASE:

THIS REPORT DUE:

14. EMPLOYEE WAGE INFORMATION FOR THIS QUARTER

EMPLOYEE

EMPLOYEE NAME (PLEASE TYPE OR PRINT)

TOTAL GROSS WAGES

PAID THIS QUARTER

SOC. SEC. NO.

LAST

FIRST

MI

DOLLARS

CENTS

Page 2

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