COMPLETING PARTS I AND II OF EMPLOYER'S QUARTERLY TAX AND WAGE REPORT, FORM DOL-4N

Part  I is designed for reporting wages  and names of employees, including corporate officers.     In the top section of  the form, you
must select the quarter ending month, enter the year, and   your Georgia Department of Labor (GDOL) account number. If you are
a  new employer  or  have not been assigned an account number,  enter  "Applied For" in the  account number  field and attach form
DOL-1A, Employer Status Report, if not previously submitted.  Enter your business name and complete mailing address.  

You must enter the  Social Security Number, full last name and full first name and total reportable gross wages for the quarter for
each employee.   Reportable   gross wages are the  total gross wages   (to include  tip wages) minus  125 Cafeteria   Plan deductions
taken during the quarter.  Wages must  be reported  for the  quarter in which wages were actually paid. If you  are an  employer with
more than 100 employees, you must file electronically by magnetic media (DVD, CD-Rom, or USB Flash Drive) or online at
http://dol.georgia.gov/file-tax-and-wage-reports-and-make-payments.

Part II is for reporting tax summary information and changes to your account. 
Line 1     Enter monthly covered employment data, as defined in Line 1.
Line 2     Show  total reportable gross wages   paid  for the quarter  (for all employees. Enter   zeros, if no wages  were   paid this
           quarter).
Line 3     Subtract non-taxable wages (wages above $9500 per employee per calendar year).
Line 4     Enter the difference between Line 2 and Line 3.
Line 5     Compute  Contribution    Tax.  Enter your  assigned  contribution    tax rate that is provided  on   your
           Annual Tax   Rate Notice. New  employers   must use  2.64%.  For tax   periods prior to January 1, 2017,
           new employers must use 2.62%.
Line 6     Compute Administrative Assessment. Effective January     1, 2017    the rate is .06% (.0006). For tax periods prior to
           January  1, 2017,  the Administrative Assessment    rate is .08% (.0008).  Administrative  Assessment  applies   to  all
           employers except   minimum  rated and maximum      rated employers   and those employers   who  have  elected to make
           payments in lieu of contribution as provided by Code Section 34-8-158.
Line 7     Compute  interest  for late payment  at 1.5%  per  month (a  month   is one  or more days  of  any calendar month
           after the due date). Interest accrues until all tax and administrative assessment are paid.
Line 8     Enter penalty if the report is filed late. Penalty required  is $20 or .05% (.0005) of   total wages, whichever    is
           greater,  for each month.  Compute  penalty as .05% (.0005) of total wages whenever total wages  for the quarter
           are more than $40,000.
Line 9     To be completed by the Department, if applicable.
Line 10    Enter the amount   owed,    adjusted by subtracting  any credit(s)   or adding  any  debit amount(s)   on  the
           account from previous quarters.

Account changes should    be  reported in Sections A-D   at the bottom of Part II  of the form. Should you   need assistance  completing
Sections A-D call 404-232-3301. Sign and submit Parts I and II together by the due date.

                              Visit dol.georgia.gov for additional filing and payment options. 

If unable to pay online, make check    or money order payable   to Georgia  Department    of Labor, include your GDOL account number
and mail to: 

                                                 Georgia Department of Labor
                                                 P. O. Box 740234
                                                 Atlanta, GA 30374-0234

                                                                                                                DOL-4N Instr. (R-12/16)
                                                                                                                EL3107

 EMPLOYER'S  QUARTERLY  TAX  AND  WAGE  REPORT  -  PART  I                                                                                                          43999 
 GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234  Tel. (404) 232-3245
                                                           REPORT FOR THE QUARTER ENDING                   ____________________
                                                                                                           Month and Year

                 Additional Wage Sheets                                                                    /
                 Must be in this format.                   DOL Account Number                              Qtr/Yr            Total Tax Rate   Form Must be Filed By

                                                                                                                                    (Employer's Name)
 Parts I & II of this report must 
 always be submitted.  Enter zeroes                                                                                                 (Street Address)
 in Total Reportable Gross Wages 
 Paid This Quarter if no wages                                                                                                      (Street Address)
 were paid for this quarter.                                                                                                                                           -
                                                                                                                             (City)           (State)              (Zip + 4)

1.Social Security Number                                   2.Employee's Full Name                                                             3.Total Individual Reportable
                                                                                                                                              Gross  Wages Paid This Quarter
                         Last                                    First

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________

 _________________       _____________________________           _____________________________                                              $ _____________________________
 PAGE   1   OF  1                               WAGE SHEETS
                                                                                                           TOTAL WAGES 
                                                                                                           FOR THIS PAGE       $    __________________________________
                                                           TOTAL REPORTABLE GROSS WAGES 
                                                           (Enter this amount on PART II, Line 2...........PAID THIS QUARTER $ _____________________________________
                                                                 MESSAGE AREA

                                                           Print                                                               Clear

                                                                                                                                                         EL3103        DOL-4N (R-1/14)

         EMPLOYER'S  QUARTERLY  TAX  AND  WAGE  REPORT  -  PART  II                                                                                                                 43999 
         GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234  Tel. (404) 232-3245
                                                                       REPORT FOR THE QUARTER ENDING                               Month
         ELECTRONIC FORM PROCESSING 
       _______________________________ 
         DO NOT staple any items to this page                                                                   /
                                                                       DOL Account Number                       Qtr/Yr      Total Tax Rate   Form Must be Filed By

                FORM ENTRY EXAMPLE : 
                (PLEASE PRINT CLEARLY)                                                                                   1         2       6 9         0           0    
                                                                                   ,                                        ,                         .
1.  For each month, report the number of 
    covered workers who worked during or
    received pay for the payroll period 
    which includes the 12th of the month.................... __________________                                 __________________           __________________
                                                               (1ST MONTH)                                      (2ND MONTH)                           (3RD MONTH)

    Total REPORTABLE GROSS WAGES Paid............            $ ____________________________
2.  This Quarter (combine all wages into one total.)  
3.  MINUS Non-Taxable Wages Paid This Quarter.......         - ____________________________

4.  TAXABLE WAGES Paid This Quarter......................      ____________________________
    Contribution Tax Due                                                                                                                                                   PARTS I & II OF  
5.           % x   taxable wages (line 4)..............        ____________________________                                                                                THIS REPORT MUST  
                                                                                                                                                                           BE SUBMITTED. 
    Administrative Assessment Due: 
6.           % x  taxable wages (line 4)...............        ____________________________
    Interest On Lines 5 and 6: See Instructions 
7.              Due After                                      ____________________________
    Penalty is for filing late, not based on total amount 
8.  due: (See Instructions) Due After                          ____________________________
9.              Balance as of                                  ____________________________

10. TOTAL AMOUNT DUE: ( SUM of lines 5 thru 9)......         $ ____________________________

UNLESS  PARTS I & II OF THIS REPORT ARE FILED AND THE TOTAL AMOUNT                 Return original forms (Parts I & II) with                                       -       -
DUE IS PAID, A FI.  FA. (TAX LIEN) WILL BE ISSUED AS REQUIRED BY LAW.              remittance to GA DEPT of LABOR                                           FOR DEPT USE ONLY
Phone (404) 232-3301      EMPLOYER CHANGE REQUEST  -  If ANY of the following items have changed, please complete the appropriate information below.
A. If you are a new employer, or the name of your business or MAILING                                                  D. If your business  was  discontinued or if a change in ownership has 
ADDRESS has changed or is incorrect, enter the correct Information                                                     occurred, please completed the  following:
below:                                                                                                                                                 (Check One)
                                                                                                                            Business                   Entire Business              Corporation  
                                                                                                                            Discontinued               Sold                         Formed
                  (Business Name)
                                                                                                                            Partners Added             Merger                       Partial Sale
                                                                                                                            or Withdrawn
                         (Street Address)
                                                                                                                            Corporate Name Change Only (Attach copy of Amendment to Charter)  
                         (Street Address)
                                                                                                                            Other (Attach Explanation)
         (City)                         (State)              (Zip + 4)
       -        -                                                                                                           Effective Date (MM/DD/YY)              /               /
                         (Phone)                             (Email Address)
B. If the PRINCIPAL LOCATION of your business operations in GEORGIA
has changed, enter the correct address below (DO NOT use a P.O. Box                                                                          (New Owner's Name)
number for Principal Location):
                                                                                                                                             (Street Address)
                  (Street Address)
                                                                                                                                             (Street Address)
                  (Street Address)
                                                                                                                                     (City)            (State)            (Zip + 4)
         (City)                         (State)              (Zip + 4)                                                             -        -
       -        -                                                                                                                    (Phone)                              (Email Address)
                         (Phone)                             (Email Address)
C. If your Federal Identification number has changed enter the correct 
number below:
                          -
If the Federal ID number changed due to a change in ownership, complete section D.                                                                                        -
       I certify that the information in this report and any subsequent pages attached is true and correct and  
       that no part of the tax was or is to be deducted from the worker's wages                                                      (Employer Name and Address)

       Signature and title of individual responsible for information provided                                                                         Phone No.                     Date
                                                                                                                                                          EL3104          DOL-4N (R-1/14)
                                                                       Print                                                       Clear