COMPLETING PARTS I AND II OF ANNUAL TAX AND WAGE REPORT
                  FOR DOMESTIC EMPLOYMENT, FORM DOL-4A

Part I
Enter  your  DOL  account number,  the  report  year,  employer  name,  mailing address,  and  email
address. Note: If  you  are a new   employer    and  have  not yet been   assigned   a  DOL account
number,  enter "Applied   For"  in  the  account   number  field  and  attach a  DOL-1A,   Employer
Status Report, if not previously submitted.

Enter the Social  Security  Number,    last name,  first name, and    total covered  wages    paid in
each  quarter  separately.  All wages  paid to  an  employee   must  be reported   by  the employer
for the quarter in which payment was actually made.

Part II

Line 1   Amount   of  total reportable gross wages paid  for all employees.  Show    the amount  paid
         for each quarter separately.
Line 2    Subtract non-taxable  wages  (amount  of wages   above $9500 per employee      per calendar
         year) as applicable for each quarter.
Line 3   Enter the   difference between  Lines  1  and   2.  This  amount is  used   to  calculate the
         amount of taxes to be paid.
Line 4   In the area  provided, enter  the  Contribution tax rate. To  calculate the Contribution  tax,
         multiply your Contribution tax  rate  by the  amount  in Line 3 for each  quarter.  Effective
         January  1,  2017, new   employers  must  use 2.64%.  For tax  periods  prior  to January 1,
         2017, new employers must use 2.62%.
Line 5   In the   area  provided, enter  the    Administrative Assessment    rate. To    calculate the
         Administrative Assessment     tax, multiply the Administrative  Assessment     rate (.06% or
         .0006  effective   January 1, 2017)   by  the amount  in Line 3  for each   quarter. For  tax
         periods  prior to  January 1, 2017,   the Administrative Assessment rate  is .08%   or .0008.
         This applies to  all employers  except employers  with   the minimum  rate  or  the maximum
         rate and those employers who have elected to make payments in lieu of contributions as
         provided by Code Section 34-8-158.

                  *The total tax rate is contribution + administrative assessment.

Line 6     The sum of Lines 4 and 5 for each quarter.
Line 7   Enter the amount of taxes previously paid for this reporting year.
Line 8   Enter the difference between Lines 6 and 7. 
Line 9   The sum of each quarter from Line 8.
Line 10  Interest is computed on the tax due    (Line 9) from  the due date  (January 31) at the rate
         of 1.5%   per   month    or   fraction of   a month.  Interest  accrues   until all tax   and
         administrative assessments are paid.
Line 11  Enter penalty if the report is  filed after January 31.  Penalty is $20 or  .05% (.0005)  of
         total wages whichever is greater, for each month the report is late.    Compute penalty as
         .05%  (.0005)  of  total wages  whenever    total wages   for  the  quarter are  more   than
         $40,000.
Line 12  Enter the sum of Lines 9 through 11.

Changes in your business information should be reported in Sections A-D at the bottom of Part II.
For assistance with   completing  Sections  A-D,  call 404-232-3301.      Sign and   mail the report,
Parts I and II, no later than January 31.

Visit dol.georgia.gov for online  payment   options  or  make  check   or money    order  payable  to
Georgia Department of Labor and provide your DOL account number on your check.

                                                                                 EL6103   DOL-4A Instr. (R-12/16)

ANNUAL TAX AND WAGE REPORT FOR DOMESTIC EMPLOYMENT -                                                                                48999 
PART I
GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234
                                                     Tel. (404) 232-3245
                                                     www.dol.state.ga.us

           DOL Account Number                        Year
                                                                                                            (Employer's Name)

                                                                                                            (Street Address)
Parts I & II of this report must always be
 submitted.                                                                                                 (Street Address)

                                                                                                     (City) (State)                (Zip + 4)

                                                                                                            (email Address)

1. Social Security Number                            2. Employee's Name  (If blank, please enter.)          3. Total Individual    For Quarter Ending
                                                                                                             Reportable Gross Wages
                                                                                                     $                             March 31
Social Security Number                                   Full Last Name, Full First Name
                                                                                                     $                             June 30
                                                                                                     $                             September 30
                                                                                                     $                             December 31

                                                                                                     $                             March 31
Social Security Number                                   Full Last Name, Full First Name
                                                                                                     $                             June 30
                                                                                                     $                             September 30
                                                                                                     $                             December 31

                                                                                                     $                             March 31
Social Security Number                                   Full Last Name, Full First Name
                                                                                                     $                             June 30
                                                                                                     $                             September 30
                                                                                                     $                             December 31

Social Security Number                                   Full Last Name, Full First Name             $                             March 31
                                                                                                     $                             June 30
                                                                                                     $                             September 30
                                                                                                     $                             December 31

Social Security Number                                   Full Last Name, Full First Name             $                             March 31
                                                                                                     $                             June 30
                                                                                                     $                             September 30
                                                                                                     $                             December 31
                                                                        TOTAL REPORTABLE GROSS 
Page 1 of 1                              Wage Sheets                            WAGES PAID THIS YEAR $

                                                                        MESSAGE AREA

                                                         Print                                     Clear

                                                                                                            EL6101                 DOL-4A (7/14)

             ANNUAL TAX AND WAGE REPORT FOR DOMESTIC EMPLOYMENT -                                                                                                                       48999 
             PART II
             GEORGIA DEPARTMENT OF LABOR - P.O. BOX 740234 - ATLANTA, GA 30374-0234
                                                                         Tel. (404) 232-3245
                                                                         www.dol.state.ga.us

       ELECTRONIC FORM PROCESSING                                                       DOL Account Number Year                    Total Tax Rate Form must be Filed By
       DO NOT staple any items to this page.
                                                                                        First Quarter               Second Quarter Third Quarter               Fourth Quarter

1.     Total REPORTABLE GROSS WAGES
        Paid Each Quarter 
2.     MINUS  Non-Taxable Wages Paid Each Quarter

3.     TAXABLE WAGES  Paid Each Quarter
4.     Contribution Tax Due: 
                    X     taxable wages  (line 3)
5.     Administrative Assessment Due:
                    X     taxable wages  (line 3)

6.     Total Amount Due:       SUM(of lines 4 and 5)
7.     Taxes Previously Paid (if any)
8.     BALANCE DUE:       Line 6(minus 7)

9. ANNUAL TAX DUE                (SUM: of line 8 for all quarters listed on this report)                                           $
10.    If report is late, amount of Interest due     :(See instructions)                                                           $
11.11. If report is late, amount of Penalty due      :(See instructions)                                                           $
12. TOTAL AMOUNT DUE             SUM of(lines 9 thru 11)                                                                           $

                                                                                                  Return these forms (Parts I & II) with
UNLESS PARTS I & II OF THIS REPORT ARE FILED AND THE TOTAL AMOUNT                                 check payable to GA DEPT of LABOR or 
                                                                                                  visit www.dol.state.ga.us for outline
DUE IS PAID, A FI. FA. (TAX LIEN) WILL BE ISSUED AS REQUIRED BY LAW.                              payment options.                                                                     /                /
                                                                                                                                                                                       FOR DEPT USE ONLY
EMPLOYER CHANGE REQUEST                                  - If     ANY     of the following items have changed, please complete the appropriate information below.  Phone (404) 232-3301
A  . If your MAILING ADDRESS has changed, or is incorrect, enter                                           B. If your PHYSICAL LOCATION has changed or is incorrect, enter 
the correct information below:                                                                             the correct information below:

                                                 (Street Address)                                                                                             (Street Address)
                                                 (Street Address)                                                                                             (Street Address)
                          (City)                                            (State)         (Zip)                                         (City)                              (State)                    (Zip)
(          )                                                                                               (           )
               (Phone)                                                                                                             (Phone)

C . If you no longer have domestic workers, please give us the last                                                 E-mail address: 
date you had such workers: 
       Effective Date (MM/DD/YY)                                  /                     /

D. If the Federal Identification number listed below is incorrect, list 
the correct number in the spaces provided:
                                                                                                                                                  (Employer's Name)

                                                                                                                                                         (Street Address)

                                                                                                                                                         (Street Address)

                                                                                                                                          (City)              (State)                    (Zip + 4)

I certify that the information contained in this report and any 
subsequent pages attached is true and correct and that no part of                                                                                        (email Address)
the tax was or is to be deducted from the worker's wages.

   Signature and title of individual responsible for information provided                                                                        Phone Number                                           Date
                                                                                                                                                  EL6102                      DOL-4A (8/14)