R. M3 M3 M3 M3 M3 M3 
. 
Q M2 M2 M2 M2 M2 M2 
 
P. M1 M1 M1 M1 M1 M1 

  ______________ 

O. (mm/dd/yy)
Gross Wages Gross Wages Gross Wages Gross Wages Gross Wages 

Electronic filing is required under 646 IAC 5-2-2 unless the employer has been pre- approved for an electronic filing waiver.  Employers must register with DWD prior to the end of the first quarter in which the employer becomes liable.  If you do not know your SUTA number, attach a copy of State Form 2837 to your return. Employers are subject to fines for missing or inadequate reports. Non-employers that advise, encourage, or facilitate a violation of the Act may be subject to Civil Penalties of up to $5000 per violation. Employee’s Gross Wages 
. 
N
Type Type Type Type Type Type 

M.
ZIP Code Zip Code Zip Code Zip Code Zip Code Zip Code 

L.
Total of this page  ________________________________________ 
_______________________ SOC Code SOC Code SOC Code SOC Code SOC Code SOC Code    
 
. 
F. Page _________ of _________ K
Indiana Department of Workforce Development ATTN: Quarterly Payroll Report 10 N. Senate Ave. SE 001  Indianapolis, IN 46204-2277  Start Date (mm/dd/yy) Hire Date Hire Date Hire Date Hire Date Hire Date 
. Total Payroll  
C J. MI MI MI MI MI MI 

I.

First Name First Name First Name First Name First Name 
_________________ 
Employee’s First Name 
See also 646 IAC 5-2-2 for employee reporting requirements.

. 
. Total Employees H
B
 Last Name Last Name Last Name Last Name Last Name 

Employee’s Last Name 

If you have any questions, call DWD at 800-891-6499 option 2 for Employer Assistance or refer to the Employer Handbook. 

 QUARTERLY WAGE AND EMPLOYMENT REPORT State Form 54256 (R5 / 2-19) / DWD Form UC-5A * This agency is requesting disclosure of your Social Security number in accordance with IC 4-1-8-1; disclosure is mandatory and     this record cannot be processed without it.   
 
G. SSN SSN SSN SSN SSN 

Print all information using dark ink in block letters.  Please provide a valid telephone number in the event the form cannot be read. Call 800‐891‐6499 for help. 
. Quarter ______  Year________ . Contact Name ___________________________________ Telephone Number (          ) _________-_____________ . SUTA Account Number _________________  FEIN ______________________  
 A D E Social Security Number * Total of all pages _______________________________________ 
Submitted by _____________________________________    Title / Relationship to Employer _________________________    Date The information contained in this report is filed under penalty of perjury. By submitting this report, the employer is certifying that it is complete and accurate to the best of the employer’s knowledge and belief.  The employer further certifies that they have read and followed the requirements explained in the Unemployment Insurance Employer’s Handbook and the instructions for this form. 

Instructions:  Reports must be in dark ink.  DWD images reports when received. Using light ink or a pencil may prevent the report 
from being processed. Reports must be legible.  Print your responses using block letters.  If there are any problems with the report, the 
employer must be available to resolve the reporting problem.  DWD will attempt to verify over the phone.  The DWD phone number 
will display as an 800#.  
You may need to file more than one page for each quarter if you employ more than 5 workers. Report only workers that received 
payment for performing services during the calendar quarter being reported. 
Employers must file one report per quarter even if they do not have any wages in the quarter.  Employers are responsible for the 
timely submission of all reports and payments to the DWD: 
           QUARTER                         QUARTER START              QUARTER STOP                    DUE DATE 
           1                               January 1 st               March 31 st                     April 30 th
           2                               April 1 st                 June 30 th                      July 31 st
           3                               July 1 st                  September 30 th                 October 31 st
           4                               October 1 st               December 31st                             st

If you are filing this report for a liable employer with no wages in the quarter, fill out sections  Athrough  .FFor part  ,Ctotal payroll, 
write 0 (zero). 
In part A, write down the quarter number for the period you are reporting and the calendar year in which the payroll was distributed 
per the above chart. 
In part B, write down the total number of workers being reported.  Include all pages of the report being filed.   
In part C, write down the total amount of payroll distributed to workers during the calendar quarter being reported.  Include all pages 
of the report being filed.   
In part D, write down a valid, employer, contact name and telephone number.   
In part E, write down the SUTA account number assigned by DWD to the employer’s account and the FEIN that will be used on the 
employee’s W-2 or 1099 for the current year.  If the employer operates under more than one FEIN, complete a new page for each 
FEIN.   
In part F, write the page number for this page of your report and the total number of pages that you are reporting.   
In part G, write down the Social Security Number or ITIN of the employee.   
In part H, write down the employee’s last name.   
In part I, write down the employee’s first name.   
In part J, write down the employee’s middle initial – leave this blank if the employee does not have a middle name.  
In part K, write down the worker’s start date with this employer.  The New Hire Reporting requirements are used to determine the 
correct Start Date if the worker has temporarily separated from the employer. 
In part L, write down the employee’s SOC (Standard Occupational Classification) code.  Call DWD for help with finding the SOC 
code for your worker.  You will need the worker’s job title or description of the work that they do for the company to complete this 
part of the form. 
In part M, write down the ZIP Code where the employee is working for the employer even if it is not the same ZIP Code that the 
employer uses as their legal or mailing address.   
In part N, write down the type of employment for this employee.  Write down the two digit seasonal code if you have seasonal 
approval from DWD, if you do not have approved seasonal status, write down FT for full time or PT for part time. 
In part O, write down the total wages paid to the employee that are subject to unemployment.  This is the Gross wage amount, not the 
taxable wage amount.  
In part P, write down a Y if the worker was active during the payroll period containing the 12 thday of the 1  monthstin the quarter. 
Write down N if the worker was not active during the payroll period containing the 12 thday of the 1 stmonth in the quarter. 
In part Q, write down a Y if the worker was active during the payroll period containing the 12  dayth of the 2  monthndin the quarter. 
Write down N if the worker was not active during the payroll period containing the 12 thday of the 2 ndmonth in the quarter. 
In part R, write down a Y if the worker was active during the payroll period containing the 12  dayth of the 3  monthrdin the quarter. 
Write down N if the worker was not active during the payroll period containing the 12 thday of the 3 rdmonth in the quarter.