MISSOURI

Missouri Department of Labor and Industrial Relations

DIVISION OF EMPLOYMENT SECURITY 2. MISSOURI EMPLOYER ACCOUNT NO.
AUDIT BLOCK
QUARTERLY CONTRIBUTION AND WAGE REPORT (DO NOT USE)

PLEASE TYPE OR PRINT THIS REPORT 3. CALENDAR QUARTER

Date
XYN Paid
1. EMPLOYER NAME AND ADDRESS

4. TOTAL WAGES PAID

5. WAGES PAID IN EXCESS

OF
PER WORKER PER YEAR

6. TAXABLE WAGES
Item 4 Minus Item 5

7. CONTRIBUTIONS DUE Due

Multiply Item 6 by Your
$0.00
RATE Pd

8. INTEREST ASSESSMENT DUE Over

TO FEDERAL ADVANCES Under

15. FEDERAL ID NUMBER 9. INTEREST CHARGES Adj/Cr.

RETURN THIS PAGE WITH REMITTANCE TO: PER MONTH $0.00 Applied

DIVISION OF EMPLOYMENT SECURITY If Paid After

PO BOX 888 10. LATE REPORT PENALTY
JEFFERSON CITY MO 65102-0888 CHARGES

(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) A. Greater of 10% or $100

B. Greater of 20% or $200

THIS REPORT IS DUE BY 11. OUTSTANDING AMOUNTS AS

GREATER OF 10% OR $100 PENALTY AFTER OF

GREATER OF 20% OR $200 PENALTY AFTER 12. ADJUSTMENT

Place X in applicable box and complete "Report on Change of TO PRIOR QUARTERS
Business Operations" on the reverse side of the instruction sheet. A. Underpayments
We have sold our business. B. Overpayments

We have ceased employment.

We have an address change.
13. TOTAL PAYMENT $0.00
Please Print 14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR
RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH
NAME

TITLE 1st 2nd 3rd

SS NO. PHONE NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER

S
I certify that the information contained in this report, SIGNATURE PHONE
T including name and address in Item 1 is true and correct.
A ADDRESS

P 16. Social Security Number

First
Initial
Middle
Initial 17. Worker Name (Last Name) 18. Total Wages Paid This Quarter 19. Probationary

L
E

C
H
E
C
K

H
E
R
E

20. PAGE 1 OF PAGES TOTAL THIS PAGE $0.00 MODES-4-7 (10-07) AI

IHE
 OF PAGES

THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

 MISSOURI
Missouri Department of Labor and Industrial Relations
DIVISION OF EMPLOYMENT SECURITY 2. MISSOURI EMPLOYER ACCOUNT NO.

QUARTERLY CONTRIBUTION AND WAGE REPORT 0

PLEASE TYPE OR PRINT THIS REPORT 3. CALENDAR QUARTER
XYN
1. EMPLOYER NAME AND ADDRESS 0
4. TOTAL WAGES PAID $0.00
0 5. WAGES PAID IN EXCESS

0 OF $0.00 $0.00 RETURN

ORIGINAL
0 PER WORKER PER YEAR
WITH ANY
0 6. TAXABLE WAGES REMITTANCE
$0.00 DUE
0 Item 4 Minus Item 5

0 7. CONTRIBUTIONS DUE
0 Multiply Item 6 by Your
$0.00
RATE .00000
8. INTEREST ASSESSMENT DUE
TO FEDERAL ADVANCES $0.00
0 EMPLOYER'S
15. FEDERAL ID NUMBER 9. INTEREST CHARGES 0 COPY
RETURN THIS PAGE WITH REMITTANCE TO: PER MONTH .00000 $0.00
DIVISION OF EMPLOYMENT SECURITY If Paid After 0
PO BOX 888 10. LATE REPORT PENALTY
JEFFERSON CITY MO 65102-0888 CHARGES
$0.00
(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) A. Greater of 10% or $100
B. Greater of 20% or $200
RETAIN
THIS REPORT IS DUE BY 0 11. OUTSTANDING AMOUNTS AS FOR
$0.00 YOUR
GREATER OF 10% OR $100 PENALTY AFTER 0 OF 0 RECORDS

GREATER OF 20% OR $200 PENALTY AFTER 0 12. ADJUSTMENT

Place X in applicable box and complete "Report on Change of TO PRIOR QUARTERS
$0.00
Business Operations" on the reverse side of the instruction sheet. A. Underpayments
0 We have sold our business. B. Overpayments

0 We have ceased employment.

13. TOTAL PAYMENT $0.00
0 We have an address change.
Please Print 14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR
RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH
NAME 0
TITLE 0 1st 0 2nd 0 3rd 0
SS NO. 0PHONE 0 NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER
S
I certify that the information contained in this report, SIGNATURE 0 0
T including name and address in Item 1 is true and correct.
PHONE

A ADDRESS 0
P 16. Social Security Number First
Initial
Middle
Initial
17. Worker Name (Last Name) 18. Total Wages Paid This Quarter 19. Probationary

L 0 0 0 0 0 0 0.00 0
E
0 0 0 0 0 0 0.00 0
C
H 0 0 0 0 0 0 0.00 0
E
C 0 0 0 0 0 0 0.00 0
K
0 0 0 0 0 0 0.00 0
H 0 0 0 0 0 0 0.00 0
E
R 0 0 0 0 0 0 0.00 0
E
0 0 0 0 0 0 0.00 0

0 0 0 0 0 0 0.00 0

20. PAGE 1 OF 0 PAGES TOTAL THIS PAGE 0.00 MODES-4-9 (10-07) AI

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 OF PAGES

THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

 MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF EMPLOYMENT SECURITY P.O. Box 888
Missouri Quarterly Wage Report Jefferson City, MO 65102-0888

CONTINUATION SHEET
Print in this space employer's name and account number as shown on Calendar Quarter/Year
Form MODES-4 Missouri Quarterly Contribution and Wage Report

Type or print in ink

0
0
First Middle
16. Social Security Number 17. Worker Name (Last Name) 18. Total Wages Paid This Quarter 19. Probationary
Initial Initial

20. PAGE 2 OF 0 PAGES TOTAL THIS PAGE $0.00

Be sure that each page carries employer's name, account number, page number and calendar quarter and year.
Return the original completed form to the Division of Employment Security, P.O. Box 888, Jefferson City, MO 65102-0888.
Retain copy for your file.
MODES-10B (12-99) AI
Cont.