&a56c8RName (as distinguished from trade name), trade name, if any, address and ZIP code
(0B(s0p10h12v0s1b0T&a68c4.5r68L
(0U(s1p6vsb4T&l5.33C&a263c17.25r263LEmployer
identification number
&l8C(0U(s1p8vsb4T&a9c15RFollow the chart under (s1BWho May Use Form 940-EZ (sBin the instructions. If you cannot use Form 940-EZ, you must use Form 940 instead.
&a15c16r15LEnter the amount of contributions paid to your state unemployment fund. (See instructions for line A.)&a3945H . . . . . . . (0B(s0p10h12v0s1b0Tj(0U(s1p8vsb4T
(1) Enter the name of the state where you have to pay contributions &a2762H . . . . . . . . . . . . . . . . . . . . . . . . (0B(s0p10h12v0s1b0Tj(0U(s1p8vsb4T
(2) Enter your state reporting number as shown on state unemployment tax return. (0B(s0p10h12v0s1b0Tj(0U(s1p8vsb4T
&a+3RTotal payments (including payments shown on lines 2 and 3) during the calendar year for services of employees
&a+1RExempt payments. (Explain all exempt payments, attaching additional sheets if
necessary.)(0B(s0p10h12v0s1b0Tj(0U(s1p8vsb4T
&a+2RPayments for services of more than $7,000. Enter only amounts over the first $7,000 paid
to each employee. Do not include any exempt payments from line 2. Do not use your state
wage limitation. The $7,000 amount is the Federal wage base. Your state wage base may
(s1BFUTA tax.(sB Multiply the wages on line 5 by .008 and enter here. (If the result is over $100, also complete Part II.)&a4293H . .
Total FUTA tax deposited for the year, including any overpayment applied from a prior year (from your records)&a4293H . .
(s1BAmount you owe(sB (subtract line 7 from line 6). This should be $100 or less. Pay to "Internal Revenue Service."&a4221H . .
(s1BOverpayment(sB (subtract line 6 from line 7). Check if it is to be :
(0U(s1p8vs1b4T&a117c37RApplied to next return, or
&a165c37RRefunded
&a33R&a4394H(0B(s0p10h12v0s1b0Tj(0U(s1p8vs1b4T
&a4394H(0B(s0p10h12v0s1b0Tj(0U(s1p8vs1b4T
&a4394H(0B(s0p10h12v0s1b0Tj(0U(s1p8vs1b4T
(0U(s1p10vs1b4T&a21R&a341.6HPart I
&a38R&a327.2HPart II
&a20c21RTaxable Wages and FUTA Tax
&a20c38r20LRecord of Quarterly Federal Unemployment Tax Liability
(0U(s1p8vsb4T&a30c38.8R(Do not include state liability.) Complete only if line 6 is over $100.
(0U(s1p6vsb4T&a23R&a4134.8HAmount paid
&a40R&a645.2HQuarter
&a40R&a1410.8HFirst (Jan.1 - Mar. 31)
&a40R&a2226.8HSecond (Apr.1 - June 30)
&a40R&a3107.6HThird (July 1 - Sept. 30)
&a40R&a3960.8HFourth (Oct. 1 - Dec. 31)
&a40R&a4986.8HTotal for year
&a41R&a468.8HLiability for quarter
(0U(s1p8vsb4T&a9c19r9L(s1BIf you will not have to file returns in the future, check here(sB (see (s1BWho Must File(sB in instructions) (s1Band complete and sign the return. (sB&a5018H . . . .
&a9c42r9LUnder penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and, to the best of my
knowledge and belief, it is true, correct, and complete, and that no part of any payment made to a state unemployment fund claimed as a credit
was, or is to be, deducted from the payments to employees.