Department of the Treasury - Internal Revenue Service
Form 940-B Request for Verification of
(Rev. May 2010)
Credit Information Shown on Form 940
Name and address of employer Date
Calendar year
Employer identification number
The Form 940 filed with the IRS by the employer named above indicates the following information for the calendar year shown.
State in Which State Reporting No. Contributions
Employees Performed as Shown on Taxable Payroll Experience Rate Experience Actually Paid
Services Employer's State (as defined in State Act) Period Rate to State
Contribution Returns (4)
(1) (2) (3) From- To- (5) (6)
State Agency: Please complete the certification below and fax or mail it back to us. Show any differences between the information shown above
and your records in the space below. Also show any contributions paid after February 1.
Fax Number: OR Mail to: Other (remarks, etc):
Director, Internal Revenue Service Center
Attention:
(FUTA Liaison)
State Reporting No. Experience Rate Contributions Contributions
as Shown on Period State Taxable Experience Paid Before Paid February 1 Contributions
Employer's State Wages Rate February 1 through Paid After
Contribution Returns February 10 February 10
From- To-
I certify that, except as shown above, the records of this office agree with the entries shown in columns (2), (3), (4), (5), and (6), and that all
contributions were paid before February 1.
Name of State Name of State Officer Date
Part 1-State Agency copy Cat. No. 20910X Form 940-B (Rev. 5-2010)