Instructions for completing the Wyoming Quarterly UI/WC and UI Only Summary Report form 

                                                                                                                                                    Substitute forms will not be accepted. 
                                                                                                                                                    Information inserted needs to be vertically and horizontally aligned.  Please do not 
                                                                                                  ABC           SAMPLE CO INC 
                                                                                                                                                    use commas, dollar signs or decimals.  Enter zeros in the “cents” column when 
                                                                                                  03/31/2016 
                                                                                                                                                    applicable Use Black Ink Only 
                                                                                                  04/30/2016
                                                                                                                                                     
                                                                                                                    1 2016                                                       Use Black Ink Only 
                                                                                                                    012345678                                            Unemployment Insurance Filing 
                                                                                                                                61738  75           Line 1: Enter Total Wages from the wage list including Corp. Officer 
                                                     (2016 TAXABLE WAGE BASE $25,500.00)                                         2180  00           wages 
                               
                                                                                                                          59558  75                 Line 2: Enter Excess Wages (if any) ** See below 
                                        
                                                                                                                                1727  20 
                                                                                                                                                    Line 4: Multiply line 3 (taxable wages) by the assigned rate and enter 
                            (INCLUDES                          .00108         FOR EMPLOYMENT .0290SUPPORT FUND)                                     Line 3: Line 1 minus line 2. Line 3 cannot be a negative number 
                                                                                                                                                0   the tax amount due on line 4 
                                                                                                                                                0   Line 5, Line 6, and Line 7: Enter as necessary 
                                                                                                                                                0   Line 8: Add line 4, line 5, line 6, and subtract line 7. Enter the result on line 8  
                            
                                                                                                                                1727  20            Line 9: (UI Only report) Enter the amount from line 8 
                                                                                                                JAN       FEB      MAR    
                                                                                                                   4            4             3       
                                                                                                                                                     Number of Workers by Month: Enter the number of employees who 
                                                                                                                    007654321                        worked on or received pay on the 12thof the month          
                                                                                                                  
   000010          1                                     5000  00           .0088                                        44  00                                                               
                                                                                                                                                                         Workers’ Compensation Filing 
  236115C        1                                   11673  51           .0560                                      653  72      
                                                                                                                                                    Column 9A: NAICS/Class Codes assigned to the account (to be used 
   236115          4                                   13978  90           .0560                                      782  82                       in A5 of the Employee Wage Listing) 
                                                                                                                                     0              Column 9B: Enter the number of employees for each NAICS/Class 
                                                                                                                                     0              Code 
                                                                                                                                     0              Column 9C: Enter the total wages for each NAICS/Class Code. (Use 
                                                                                                                                                    the WC Average Wage of $11,673.51 for 2016 to report Corp. Officer 
                                                                                                                                     0 
                                                                                                                                                    wages if the NAICS/Class Code ends in the letter C) 
                                                                                                                                     0              Column 9E: Multiply each wage amount from column 9C by the 
                                                             6 30562  41                                                         1480  54           Rate(s) in 9D and enter the results for each line 
                                                                                                                                                0   Line 10: Enter totals for columns 9B, 9C, and 9E 
                                                                                                                                                    Line 11, Line 12, and Line 13: Enter as necessary 
                                                                                                                                                0 
             4/15/16                                                                                                                            0     
                       307-123-4567                                                                                             1480  54            Line 14:         Enter the total Workers’ Compensation tax due 
                                                                                                                                1727  20            Line 15:         Enter the total Unemployment tax due from Line 8 above 
                Joe Sample                                                                                                                          Line 16:         Enter the results of Line 14 plus Line 15 
                                                                                                                                3207  74 
          President                                                                                                                                 This is the amount of payment that should be sent for UI and WC taxes  
                                                                                                                                                    Make Checks payable to: Department of Workforce Services 
                                                                                                                                                    
 ** Excess wages are any wages for an Employee over the taxable wage base for the year. The Taxable Wage Base for 2016 is $25,500.00 
 Note: Once the taxable wage base       has been met, excess wages cannot exceed the quarter’s total wage for the employee. To correct or file reports for a prior quarter 
 call (307) 235-3217 or visit our website at: http://www.wyomingworkforce.org to obtain forms. 
                                                                                                                                                                                                                    07WYS104066 
  

                                                                                                                                        To correct or file reports for a prior quarter call 
            Instructionsfor completing the Wyoming Employee Wage Listing                                                                (307) 235-3217 or visit our website at: 
                                                                                                                                        http://www.wyomingworkforce.org to obtain forms. 
                                                                                                                                         
                                                                                                                                        Do not enter more than 12 employees or 4 
                                                                                                                                        Corporate Officers per page. To obtain additional 
                        1 2016                                                     ABC   SAMPLE CO INC                                  blank forms call (307) 235-3217. 
                            012345678                                              111 SAMPLE RD                                         
                                                                                   SAMPLE TOWN, US 111111 
                            007654321                                                                                                   Substitute forms will not be accepted. 
                                                                                                                                         
   123 45 6789       JONES SAM                                       1899  00     236115            B 01  20   2016       236            
   223 45 6789        SMITH TOM                 30  35                3543  45     236115                                        294B                 USE BLACK INK ONLY 
                                                                                                                                        *A1: Enter the Social Security Number of each 
   323 45 6789        BROWN DON                                        7762  45    236115                                        659 
                                                                                          B                                             covered employee receiving wages during this quarter 
    423 45 6789        SIMPSON ABLE          49  50                  774  00       236115            B  02   13   2016        86        *A2: Enter the Last and First Name of the employee 
   523 45 6789        SAMPLE TERRI                                    5000  00    000010                                         200B   identified by the Social Security Number in item A1 
                                                                                                                                        A3: Enter the amount of tips each employee earned 
                                                                                                                                        during this quarter. NOTE: Tips are included as wages 
  
                                                                                                                                        for UI tax computations but not included as wages for 
                                                                                                                                        WC tax computations.  Enter the Tips subtotal at the 
                                                                                                                                        bottom of this 
                                                                                                                                        column (A3) 
                                                                                                                                        *A4: Enter the total of all wages, excluding tips, 
                                                                                                                                        earned by each employee during this quarter. Enter the 
                                                                                                                                        subtotal of wages at the bottom of this column (A4a) 
                                                                                                                                        A5: Enter the NAICS/Class Code for each employee 
                                    79 85                                   18978  90                        19058 75                   as assigned by WC (see 9A of the Quarterly UI/WC 
                                                                                                                                        Summary report). 
                                                                                                                                        Required if filing both UI and WC on this 
                                                                                                                                        form 
  623 45 6789        SAMPLE JOE          11673 51               27680  00   236115C        B                           647 
                                                                                                                                        *A6: Enter the appropriate type for each 
  723 45 6789        SAMPLE SALLY                                  15000  00                      U                    200              employee: 
                                                                                                                                              · B if covered by both UI and WC 
                                                                                          
                                                                                                                                              · U if covered only by UI 
                                11673  51                          42680  00                                    61738  75                     · W if covered only by WC 
                                                                                                                                        A7: Enter the date of hire for each employee 
                                                                                                                                        hired during this quarter 
                         CORPORATE OFFICER/LLC MEMBER INFORMATION 
                                                                                                                                        A8: Enter the hours each employee worked 
 A9: Enter the Workers’ Compensation Corporate Officer/LLC Member/Owner average wage only if Workers’ 
                                                                                                                                        during this quarter, rounded to the nearest hour. 
 Compensation Corporate Officer/LLC Member/Owner coverage has been elected and a class code ending in the letter 
                                                                                                                                        Do not use fractions or decimals (Salary use 522 hrs.) 
 “C” has been assigned to the account (see 9A of the Quarterly UI/WC Summary report). Do not use actual wages in 
                                                                                                                                        *A3+A4a: Enter the subtotal of Tips and Wages 
 this field (to report actual wages see A4 instructions below). Enter the subtotal at the bottom of this column (A9). 
                                                                                                                                        for the employees 
 A4: Enter the actual wages, including tips, earned by each Corporate Officer (required for UI) or LLC Member 
                                                                                                                                        *A3+A4a+A4b: Enter the grand total of all 
 (optional for UI) during the quarter. Enter the subtotal at the bottom of this column (A4b) 
                                                                                                                                        employee and corporate officer wages 
  
 Workers Compensation Corporate Officer Average Wage for 2016 is $11,673.51 
                                                                                                                                        *Required Field