NH EMPLOYMENT SECURITY
                                                                                                       ATTN: CASHIER
                                                                                                       PO BOX 2058
                                                                                                       CONCORD, NH 03302-2058
                                                                                                       PHONE: (603) 224-3311     www.nhes.nh.gov
                                                                                                       YOU CAN FILE THIS REPORT ONLINE 
                                                                                                           AT www2.nhes.nh.gov/webtax

                 EMPLOYER QUARTERLY TAX REPORT
1. EMPLOYER NAME & ADDRESS                                                             2. STATE EMPLOYER NUMBER     3. FOR CALENDAR QUARTER

                                                                                       4. NAME CONTROL              5. DUE DATE

                                                                                       6. FEDERAL ID NUMBER

                                                                                       NO  EMPLOYMENT - IF NO EMPLOYMENT WAS FURNISHED 
                                                                                       DURING THE QUARTER, ENTER ZEROS ON LINE 8.

See more instructions on separate sheet. Must send back original (no photocopies). Must be typewritten or printed in black ink in all capital letters.
Do not print commas, or $ signs.
                                                                                       1st MONTH 2nd MONTH          3rd MONTH
7.  FOR EACH MONTH, REPORT THE NUMBER OF COVERED WORKERS WHO 
    WORKED DURING OR RECEIVED PAY FOR ANY PART OF THE PAYROLL 
    PERIOD WHICH INCLUDES THE 12TH OF THE MONTH. IF NONE ENTER ZERO.
8.  TOTAL GROSS WAGES PAID THIS QUARTER
    (MUST AGREE WITH LINE 24)
9.  WAGES PAID THIS QUARTER IN EXCESS OF 
    PER EMPLOYEE THIS YEAR (see instructions)         $14,000

10. NET TAXABLE WAGES (SUBTRACT LINE 9 FROM LINE 8)
11. UNEMPLOYMENT INSURANCE (UI) TAX DUE             UI TAX
    (MULTIPLY LINE 10 BY TAX RATE)                  RATE                              %
12. ADMINISTRATIVE CONTRIBUTION (AC) DUE            AC
    (MULTIPLY LINE 10 BY RATE)                      RATE                              %
    DO NOT INCLUDE THIS AMOUNT WHEN FILING FEDERAL UNEMPLOYMENT TAX RETURN (FUTA)
13. TOTAL TAX DUE
    (ADD LINES 11 AND 12)

14. IF PAYMENT IS DELINQUENT ADD 1% PER MONTH ON TOTAL TAX DUE
    IF REPORT IS DELINQUENT ADD FEE FOR LATE FILING
15. (10% OF TAX DUE - MINIMUM $25)
16.

17. PAY THIS AMOUNT (TOTAL LINES 13 THROUGH 16)
    (IF UNDER $1.00 NO PAYMENT DUE)
18. PREPARED BY
                                         SIGNATURE
                                                                                       MAKE CHECK PAYABLE TO: STATE OF NH - UC
    PREPARERS TELEPHONE NO. (          )
    TAXPAYER                                                                           MAIL CHECK, ORIGINAL COPIES OF BOTH PARTS OF THE REPORT TO:
                                                                                                 NH EMPLOYMENT SECURITY
    AUTHORIZED SIGNATURE                      TITLE                              DATE            ATTN: CASHIER
                                                                                                 PO BOX 2058
ANY BUSINESS CHANGES/CORRECTIONS SHOULD BE MADE ON THE ATTACHED CHANGE NOTICE                    CONCORD, NH 03302-2058

                                                                                             NH EMPLOYMENT SECURITY
                                                                                             ATTN: CASHIER
                                                                                             PO BOX 2058
EMPLOYER QUARTERLY WAGE REPORT                                                               CONCORD, NH 03302-2058
                                                                                    PHONE: (603) 224-3311       www.nhes.nh.gov
                                                                                    YOU CAN FILE THIS REPORT ONLINE 
                                                                                    AT www2.nhes.nh.gov/webtax
1. EMPLOYER NAME & ADDRESS                                          2. STATE EMPLOYER NUMBER 3. FOR CALENDAR QUARTER

                                                                    4. NAME CONTROL          5. FEDERAL ID NUMBER

See more instructions on separate sheet. Must send back original (no photocopies). Must be typewritten or printed in black ink in all capital letters.
Do not print commas, or $ signs.
                                                                         21. FIRST  22. TOTAL GROSS WAGES THIS QUARTER
19. EMPLOYEE SOCIAL SECURITY NUMBER 20. EMPLOYEE LAST NAME                INITIAL   DOLLARS                     CENTS

                                    24. TOTAL WAGES PAID FOR ENTIRE                 23. WAGE TOTAL FOR THIS PAGE
                                    REPORT (SAME AS LINE 8)

                                                                    0.00                                        0.00

YOU CAN FILE THIS REPORT ONLINE             INSTRUCTIONS FOR PREPARING QUARTERLY TAX AND WAGE REPORT
AT www2.nhes.nh.gov/webtax
FILING A REPORT - The law requires a liable employer to file a Quarterly Tax and Wage Report and to pay contributions due on or before the last day of the month 
following the close of the calendar quarter.
Must send back original (no photocopies). Must be typewritten or printed in black ink in all capital letters. Do not print commas, decimals, $ signs, or 
dashes.
Employers reporting 50 or more employees must file their wage reports electronically (Rule EMP 302.02(d). Please file using our online WEBTAX application at 
www2.nhes.nh.gov/webtax or on magnetic media suitable for computer processing. Visit our website for more information on magnetic media reporting.

A REPORT MUST BE FILED EVEN IF NO WAGES WERE PAID DURING THE CALENDAR QUARTER. JUST ENTER ZEROS ON LINE 8.

AMENDED REPORT - This tax report cannot be used to amend prior quarters. Please contact the Department for adjustment forms.
                                                                         PART 1 (TAXES)
Lines 1- 6.  Self explanatory.                                                   Line 12.  ADMINISTRATIVE CONTRIBUTION (AC) DUE: Multiply amount in 
                                                                                           line 10 by the rate shown. (Do not include this portion of your 
Line 7.  Enter for each month in the quarter, the number of all full and                   payment on your FUTA form)
         part-time covered workers who earned or received wages in 
         New Hampshire during the pay period which includes the 12th of each     Line 13.  TOTAL TAX DUE - The total of lines 11 and 12 is the total tax due to the 
         month. This count will include all employees regardless of the total              State of NH.
         of wages paid thus far in the calendar year. Enter zeros if there is no 
         employment for a month.                                                        Example line 10              Taxable wages            =     $14,000.00
                                                                                                line 11              X UI Tax Rate 3.5%     =                $490.00
Line 8.  GROSS WAGES PAID FOR QUARTER - Enter the total of all wages,                           line 12              X AC Tax Rate 0.2%     =                $28.00
         including commissions and bonuses, paid to every individual, 
         including corporate officers who rendered services (as defined by the                  line 13              TOTAL TAX DUE            =              $518.00
         law) during the quarter. Include value of payment in kind, e.g. room                                (if under $1.00, no payment due)
         and meals. Note: Report all wages paid to part-time and temporary 
         employees. Tips received directly from a customer reported in writing   Line 14.  INTEREST ON TAX DUE - Interest is due on the tax if not paid in a 
         to the employer must be reported as wages as must tips received and               timely manner.
         distributed by the employer.
                                                                                 Line 15.  PENALTY FOR A DELINQUENT REPORT - A report not submitted timely 
Line 9.  LESS WAGES PAID IN THIS QUARTER IN EXCESS OF THE TAXABLE                          is subject for a late filing fee. Reports to be considered timely must be 
         WAGE BASE - For each employee, who has earned in excess of the                    post marked no later than the first day of the month next succeeding 
         taxable wage base thus far in the calendar year enter the amount in               the due date. If a postage meter is used must be received within 4 
         excess of the base (shown in line 9) that was paid during the quarter             business days next succeeding the due date. A 30 day extension 
         covered by this report (see sample worksheet at the bottom of the                 can be applied for $50. Must reach us before due date along with 
         page).                                                                            contributions due.
Line 10  NET TAXABLE WAGES - Deduct the amount shown in item 9 from              Line 16.  This line will contain any balance due or credit on the account.
         the amount in line 8. The difference represents total taxable wages.
                                                                                 Line 17.  Add tax report lines 13, 14, 15, and 16. Pay this amount.
                               TAXABLE WAGE BASE                                           If the amount is less than $1.00, no payment is necessary.
         $8,000 1994 - 2009 Quarters        $12,000      All 2011 Quarters
         $10,000  All 2010 Quarters         $14,000      All 2012 Quarters       Line 18.  Each return shall be signed by the preparer and the taxpayer or 
                                                         and after                         duly authorized Representative.

Line 11. UNEMPLOYMENT INSURANCE (UI) TAX DUE THIS QUARTER - Multiply 
         amount shown in item 10 by the UI tax rate shown. (This is the only 
         portion of your payment which is reportable to the IRS on your 940 or 
         940 EZ Federal Unemployment Tax Return - FUTA)
         Example:                    John Doe, the only employee, earns $6,000 per quarter. His wages should be reported as shown:
                                                         1st Quarter             2nd Quarter                 3rd Quarter           4th Quarter
         GROSS (Line 8)                                  $6,000                  $6,000                      $6,000                $6,000
         EXCESS (Line 9)                                 $0                             $0                   $4,000                $6,000
         TAXABLE (Line 10)                               $6,000                  $6,000                      $2,000                $0

SUCCESSOR EMPLOYERS - Determined by this department may use an employee’s wages previously reported by a predecessor employer when determining excess 
wages within the same calendar year.
MULTI-STATE EMPLOYERS - Whose employees work in two or more states in one year, should use all of an individual’s wages previously reported in another state when 
determining excess wages reportable in the calendar year.
                                                                         PART 2 (WAGES)
Lines 19-22.  Enter employee’s Social Security Number, last name, first initial, and total gross wages paid during the quarter. 
Line 23  Enter the total wages listed on this page. Each additional page listing must also have a page total.
Line 24. Enter the total wages paid during the quarter. This entry must be the same as line 8, part 1 of this report.
Mail report to NH Employment Security Attn: Cashier PO Box 2058 Concord, NH 03302-2058.    For Assistance Call (603) 224-3311      website: www.nhes.nh.gov