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ION EMPLOYER NAME AND MAILING ADDRESS U.I. NUMBER: ABC COMPANY QUARTER ENDING: DUE DATE: Payroll Department CONTACT PERSON P O Box 999 NAME: Sue Smith TITLE: Accountant PHONE: 219-236-1072 EXT: 40 Anytown, IN 46200-0000 NAME (DIVISION,SUBSIDIARY,ETC.) NUMBER OF EMPLOYEES STREET ADDRESS (PHYSICAL LOCATION) (Includes the 12th of the month) CITY, STATE, & ZIP CODE WORKSITE DESCRIPTION (STORE #,PLANT NAME,ETC.) 00001 2210 2033 097 00002 1580 5149 003 00003 3400 5149 043 00000000-0 30-.

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