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.  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 (.08% or 
           .0008) by the amount in Line 3 for each quarter.  This applies to all employers except 
           employers with the minimum rate or the maximum rate.
                   *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 www.dol.state.ga.us 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-8/14)

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)