EMPLOYER'S QUARTERLY                                    YOU CAN FILE THIS REPORT 
                                          STAPLE CONTINUATION SHEET HERE                     TAX AND WAGE REPORT                               ONLINE AT DES.NC.GOV 
                                               BEHIND THIS PAGE

                                                                           DO NOT USE THIS FORM IF REPORTING 10 OR MORE WAGE ITEMS
                                                                                                            QUARTER ENDING                  DUE DATE              ACCOUNT NUMBER 

                                                                                                                                                                                 Qtr/Yr 
                                                                                                                       TAX RATE                             % 
                                                                                                            1. NUMBER OF COVERED WORKERS    1ST MONTH             2ND MONTH 3RD MONTH 
                                                                                                            WHO WORKED DURING OR
                                                                                                            RECEIVED PAY FOR THE PAYROLL 
                                                                                                            PERIOD WHICH INCLUDES
                                                                                                            THE 12TH OF THE MONTH
                                                                                                            2. WAGES PAID THIS QUARTER 
                                                                                                            SUBJECT TO THE LAW
                                                                                                            3. LESS EXCESS WAGES

                                          CK AMOUNT                              DATE  COLL  INITIAL        4. WAGES SUBJECT TO TAX

                                          R/CK                             LFP.W LPP.W                      5. TAX DUE FOR THIS QUARTER

                                                                                                            6. INTEREST

                                                                                                            7. PENALTY - LATE FILING
                                          CHECK THIS BOX IF THE ADDRESS HAS CHANGED
                                                                                                            8. PENALTY LATE PAYMENT 

                                                                                                            9. AMOUNT OF REMITTANCE 
                                                                                                            PAYABLE TO:
                                                                                                            DIVISION OF EMPLOYMENT SECURITY 

OUR RECORDS SHOW YOUR FEDERAL TAX                                                                                                                     . IF INCORRECT, ENTER CORRECT 
NUMBER AS  NUMBER HERE:                                                                                     .  IF ANY CHANGES OCCURRED IN THE OWNERSHIP, TELEPHONE NUMBER OR 
ADDRESS, COMPLETE FORM NCUI 101-A.   
                                                                                 10. SOCIAL SECURITY NUMBER 11. EMPLOYEE NAME                        12. SEASONAL 13. WAGES PAID

                     PAPER CLIP CHECK HERE

                                               REMOVE  & DISCARD CHECK STUB

                                                                                                                                            14. PAGE TOTAL
THE  INFORMATION  CONTAINED  IN  THIS  REPORT  IS  TRUE  AND  CORRECT  TO  THE  BEST  OF  MY  KNOWLEDGE.                                              
SIGNATURE                                                                              TITLE                                  TELEPHONE NUMBER                              DATE

NCUI 101                                       THIS REPORT MUST BE FILED BY THE DUE DATE TO AVOID PENALTIES AND INTEREST. 
Rev:  11/21

              INSTRUCTIONS FOR COMPLETING FORM NCUI 101, EMPLOYER'S QUARTERLY TAX AND WAGE REPORT 
               Do not use this form if reporting 10 or more wage items, go to des.nc.gov to file your report online.

ITEM 1: For each month in the calendar quarter, enter the number of all full-time and part-time workers who worked during or received pay for the 
       payroll period  which  includes  the 12th of  the month. 

ITEM 2: Enter all wages paid to all employees, including part-time and temporary, in this calendar quarter. If the legal business is: 

       (A) CORPORATION, the wages paid to all employees who performed services in North Carolina should be reported. Corporate officers
       are employees and their wages and/or draws are reportable.
       (B) A PARTNERSHIP, the draws or payments made to general partners should not be reported.
       (C) A PROPRIETORSHIP, the draws or payments made to the legal owner of the business (the proprietor) should not be reported. Wage paid
          to the children of the proprietor under  the age of 21 years, as well as wages paid to the spouse or parents of the proprietor,
          should not be reported.
        Special payments given in return for services performed, I.E., commissions, bonuses, fees, prizes, are wages and reportable under the 
        Employment Security Law of North Carolina. These payments (or dollar value of the gifts/prizes) are to be included in the payroll of each 
        employee by the employer for the calendar quarter(s) in which they are given.  

       If no wages were paid, enter NONE. 

ITEM 3: Enter the amount of wages paid during this quarter that is in excess of the applicable North Carolina taxable wage base. This entry cannot  
           be more than item 2. 

          Example: An employer using the 2012 taxable wage base of $20,400 and reporting one employee, John Doe, earning $6,000 per quarter. 

                                           1ST QTR     2ND QTR     3RD QTR       4TH QTR 
                                           ITEM 2:   $6,000.00     $6,000.00     $6,000.00      $6,000.00 
                                           ITEM 3:        -0-                 -0-                   -0-          $3,600.00 
                                           ITEM 4:   $6,000.00     $6,000.00     $6,000.00      $2,400.00 
ITEM 4: Subtract Item 3 from Item 2. THE RESULTS CANNOT BE A NEGATIVE AMOUNT. 

ITEM 5: Multiply Item 4 by the tax rate shown on the face of this report.   (Example:  .012% = .00012) If the tax due is less than $5.00, you do not have to 
       pay it, but you must file a report. 
NOTE:  ITEMS 6,7, AND 8 MUST BE COMPUTED ONLY IF THE REPORT IS NOT FILED (POSTMARKED) BY THE DUE DATE. 

ITEM 6: Multiply the tax due (Item 5) by the current interest rate for each month, or fraction thereof, past the due date. The applicable interest rate   
may be obtained at des.nc.gov or by contacting the nearest Division of Employment Security Office.
ITEM 7:  Multiply the tax due (Item 5) by 5% (.05) for each month, or fraction thereof, past the due date. The maximum late filing penalty is 25% 
(.25). 

ITEM 8: Multiply the tax due (Item 5) by 10% (.1). The minimum late payment penalty is $5.00. 
ITEM 9: Enter the sum of Items 5, 6, 7 and 8. Remittance should be made payable to the Division of Employment Security. 

IF  YOUR  FEDERAL  IDENTIFICATION  NUMBER  AS  PRINTED  ON  THE  REPORT  IS  INCORRECT,  ENTER  THE  CORRECT  NUMBER  IN  THE 
SPACE  PROVIDED.    STATE  TAX CREDITS  WILL  BE  REPORTED  TO  THE  INTERNAL  REVENUE  SERVICE  USING  THIS  NUMBER.    IF  YOUR 
FEDERAL IDENTIFICATION NUMBER IS NOT PREPRINTED; ENTER IT IN THIS SPACE. 

ITEM 10: Enter the federal Social Security number of every worker whose wages are reported on this form. 

ITEM 11:  Enter the name of every worker whose wages are reported on his form.  If the last name is listed first, it must be followed by a comma. 

ITEM 12: Enter an 'S' in this space if the wages reported are seasonal, otherwise leave this space blank. To report seasonal wages you must have  
       been determined a seasonal pursuit by this agency. 
ITEM 13: Wages are reportable in the quarter paid to the employee, regardless of when the wages were earned. Enter each worker's total quarterly 
       wages paid, whether or not the worker has exceeded the taxable wage base for this year. Do not show credit or minus amounts to adjust for 
          over-reported wages in prior quarters. Request, or download from www.ncesc.com.  Forms NCUI 685 for each quarter to be corrected. 
ITEM 14: Enter the sum of wages shown in Item 13 for this page only. The sum of the page totals of all pages must equal the amount shown in Item 2. 
                                           Additional information is available at:  des.nc.gov 

(Rev. 11/2021)