Creator:Tracy Hall
Date Created:March 28, 1972
Place Created:
Keywords:Tracy hall,Department of Employment Security
Context:employer's quaretly contribution report form
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FORM 3, REV 7-1-71
UTAH DEPARTMENT OF EMPLOYMENT SECURITY
1234 SOUTH MAIN STREET, P O BOX 11800, SALT LAKE CITY, UTAH 84111
EMPLOYER S QUARTERLY CONTRIBUTION REPORT
I	QUARTER 7	DELINQUENT AFTER	u	, 1
1. EMPLOYER'S UTAH REGISTRATION NUMBER, NAME AND ADDRESS: (IF INCORRECT MAKE NECESSARY CHANGES. INCLUDE ZIP CODE.)
10 01 70	25 7391 67297
M TRACY HAIL
P 0 -<fJX 1 33 UNIVERSITY STA PR iv ; UTAH	84601
CONTRIBUTION RATE
AUDITED
HH REFUND CONTR__
DEF"Y
INT..
PEN'Y._
TOTAL.
NO.
2. ENTER NUMBER OF COVERED WORKERS IN UTAH WHO WORKED DURING OR RECEIVED PAY FOR ANY PART OF THE PAY PERIOD WHICH INCLUDED THE 12TH OF EACH MONTH.
SEE INSTRUCTION C.
1st month
2ND month
3RD month
3. ENTER NUMBER OF NEW HIRES MADE IN UTAH. during the quarter. see instruction d.
Quarterly Total
items 2 & 3 must be completed,
COMPUTATION OF PAYMENT
4.	TOTAL WAGES paid this quarter for covered employment, to nearest dollar.
5.	less wages in EXCESS OF $4200. paid each worker. see instruction f.
6.	net TAXABLE WAGES paid this quarter.
7.	CONTRIBUTION due this quarter, multiply item 6 by rate above.
8.	INTEREST if contribution is delinquent - - - 1 % per month.
9.	PENALTY if delinquent - - - not less than $2.50 - - - see instruction h.
10. TOTAL payment --- add items 7, 8 & 9
11. ARE THERE INCLUDED IN ITEM 4 BONUSES OR LUMP-SUMS PAID FOR A PERIOD OF SERVICE OF MORE THAN 3 MONTHS?
YES
NO
IF YES LIST AMOUNT OF PAYMENT - SEE INSTRUCTION L BEFORE COMPLETING.
$
PERIOD OF SERVICE FOR WHICH BONUS OR LUMP SUM PAYMENT WAS PAID.
FROM:. TO:
make checks payable to utah unemployment compensation fund do not make adjustments hereon for correction of prior quarters - see instruction j.
12. EMPLOYEE'S SS NO.
13. NAME OF EMPLOYEE
16. TOTAL WAGES ALL PAGES.
MUST AGREE WITH ITEM 4.
14. TOTAL WAGES PAID
15. TOTAL WAGES THIS PAGE
FOR AGENCY USE ONLY
A REPORT MUST BE FILED.
_IF YOU PAID NO WAGES, WRITE "NONE" IN ITEM 4, SIGN AND RETURN.
I CERTIFY THE INFORMATION CONTAINED ON THIS REPORT AND ATTACHMENTS IS TRUE & CORRECT.
SIGNED
%/, tUA
EMPLOYER - KEEP THIS COPY
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