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Y USE PAPER CLIPS PLEASESEE INSTRUCTIONS FOR INFORMATION ON COI 4PLETING THIS FORM.YOU MUST USE CHANGEFORM5208 C FOR ANY CHANGETO BUSINESSSTATUS OR ADDRESS.TO FINDMORE INFORMATION ON UNEI 4PLOYI 4ENT SECURITYINTERNETSITE INSURANCETAX FORMS,YOUMAY REFERTOEMPLOYMENT VVWW.WA.GOV/ESDT AX OR CALL THE EIVPLOYERHELPLINETOLL FREE AT 1-888-836-,I9OO. TELETYPEWRITER/TELECOM(TTY), 1-800.833.6388. 1) DUE DATE 3) UBI NUMBER 2) FEDERALI D N U M B E R EI 0 4 3 o R oc o o X o 4 QTR ENDINGDATE ffiFloTd.

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