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Get MO MODES-4 2013

PAGE PAGES TOTAL THIS PAGE THIS FORM IS READ BY A MACHINE. PLEASE TYPE OR PRINT THIS REPORT. MODES-4-7 09-13 AI IHE. MISSOURI DIVISION OF EMPLOYMENT SECURITY QUARTERLY CONTRIBUTION AND WAGE REPORT YOU MAY FILE THIS REPORT BEGINNING ON THE SECOND BUSINESS DAY AFTER THE QUARTER ENDS AT www. Ustar. labor. mo. gov Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. 2. MISSOURI EMPLOYER ACCOUNT NO. AUDIT BLOCK DO NOT USE 3. CALENDAR QUARTER Date Paid MUST HAVE AMOUNT IN 4 5 6 EVEN IF ZERO 4. TOTAL WAGES PAID 5. WAGES PAID IN EXCESS OF PER WORKER PER YEAR See instruction sheet 1. EMPLOYER NAME AND ADDRESS 6. TAXABLE WAGES Item 4 Minus Item 5 7. TAXES DUE Due Multiply Item 6 by Your Pd RATE 8. INTEREST ASSESSMENT DUE Over TO FEDERAL ADVANCES Under 9. INTEREST CHARGES Adj/Cr. PER MONTH 15. FEDERAL ID NUMBER Applied If Paid After IF MAILING RETURN THIS PAGE WITH REMITTANCE TO P. O. BOX 888 JEFFERSON CITY MO 65102-0888 MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY OR PAY ONLINE AT www. labor. mo. gov/DES/Employerpayments THIS REPORT IS DUE BY 10. LATE REPORT PENALTY CHARGES See middle block to the left 11. OUTSTANDING AMOUNTS AS 12. AUTOMATION SURCHARGE GREATER OF 10 OR 100 PENALTY AFTER Business Sold Place X in applicable box and complete Report on Change of Business Operations. Employment Ceased Change of Address Please Print 13. TOTAL PAYMENT 14. FOR EACH MONTH ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR RECEIVED PAY FOR THE PERIOD THAT INCLUDES THE 12TH OF THE MONTH NAME S T A P L E 1st TITLE PHONE SS NO. 16. Social Security Number 3rd NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER PRINT I certify the information contained in this report including name and address in Item 1 is true and correct. First Initial 2nd Middle ADDRESS 17. Worker Name Last Name 18. Total Wages Paid This Quarter 19. Probationary C H K R 20. 2. MISSOURI EMPLOYER ACCOUNT NO. AUDIT BLOCK DO NOT USE 3. CALENDAR QUARTER Date Paid MUST HAVE AMOUNT IN 4 5 6 EVEN IF ZERO 4. TOTAL WAGES PAID 5. WAGES PAID IN EXCESS OF PER WORKER PER YEAR See instruction sheet 1. EMPLOYER NAME AND ADDRESS 6. TOTAL WAGES PAID 5. WAGES PAID IN EXCESS OF PER WORKER PER YEAR See instruction sheet 1. EMPLOYER NAME AND ADDRESS 6. TAXABLE WAGES Item 4 Minus Item 5 7. TAXES DUE Due Multiply Item 6 by Your Pd RATE 8. INTEREST ASSESSMENT DUE Over TO FEDERAL ADVANCES Under 9. TAXABLE WAGES Item 4 Minus Item 5 7. TAXES DUE Due Multiply Item 6 by Your Pd RATE 8. INTEREST ASSESSMENT DUE Over TO FEDERAL ADVANCES Under 9. INTEREST CHARGES Adj/Cr. PER MONTH 15. FEDERAL ID NUMBER Applied If Paid After IF MAILING RETURN THIS PAGE WITH REMITTANCE TO P. INTEREST CHARGES Adj/Cr. PER MONTH 15. FEDERAL ID NUMBER Applied If Paid After IF MAILING RETURN THIS PAGE WITH REMITTANCE TO P. O. BOX 888 JEFFERSON CITY MO 65102-0888 MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY OR PAY ONLINE AT www. .

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