Ui 5 Form – Fill Out and Use This PDF

Montana Employer’s Unemployment Insurance (UI)

Quarter End

Due Date

Quarterly Wage Report – Form UI-5

Employer Identification Numbers

UI Account Number

Federal Id (FEIN)

UI Contribution Rate

UI Administrative Fund Tax Rate

UI Total Tax Rate

UI Annual Taxable Wage Base

(Each Employee)

$29,000.00

Step 1. Check

No Wages paid for the quarter covering this report

applicable boxes

Sold Business – Name, address and phone number of new owner:

and provide

Ceased Employing – Last payroll date ______/_____/_____

information

Change in Name, Address, Phone Number or Identification Number (list corrections here): ______________________

Amended Report

requested:

Step 2. Unemployment Insurance Employee Wage Listing

Check here if wage listing is attached.

Employee’s Social

Name of Employee

Total Wages

Excess Wages

Security Number

Last Name

First Name

Paid this Quarter

This Quarter

Totals

Step 3. Calculate Tax

State Unemployment

Step 4. Number of

Insurance Tax

UI Employees

1.

Total wages paid this quarter

>

Number of covered

2.

UI excess wages (Except Governmental and Reimbursable Accts.)

>

workers who worked

3.

UI taxable wages (line 1 minus line 2)

>

during, or received pay

for, the payroll period

4.

UI total tax rate

that includes the 12th day

5.

Total tax (multiply line 3 times line 4)

of the month:

6.

Credits (overpayment from prior quarters)

1st month ____________

7.

Adjustments to prior quarters (attach explanation)

2nd month ____________

8.

Balance due (line 5 – line 6 +/- line 7 -- see instructions)

9.

If filing late, add penalty ($25) and interest (line 8 x 1.5% x month(s) past due)

rd

3 month _____________

10.

Payment enclosed (line 8 +9)

>

Make Check Payable to Unemployment Insurance Division

Mail to:

I certify the information on this report is true and correct.

Unemployment Insurance

Date:

Contributions Bureau

Authorized Signature

Telephone Number

Name of Contact Person

Telephone No

PO Box 6339

Helena MT 59604-6339

Mail this form with your check to the Unemployment Insurance Contributions Bureau

UI-5 Revised 7/14