NAICS	           AUD	     CO

                                                    EMPLOYER’S QUARTERLY CONTRIBUTION AND WAGE REPORT
                                                               ARKANSAS DEPARTMENT OF WORKFORCE SERVICES
                                                    P.O. BOX 8007 LITTLE ROCK, ARKANSAS 72203-8007  (501) 682-3798

                                                                                                               DWS ID NUMBER
                                                                                                               DATE QUARTER ENDED
                                                                                                               FEDERAL ID NUMBER
                                                                                                               REPORT DUE DATE
                                                                                                               Check box and return if no wages paid c

PART A.                                                                                                            1st  mo          2nd  mo    3rd  mo
	                                 1.	 Number	of	employees	in	the	pay	period	including	the	12th	of:	                of qtr _________  of qtr _________  of qtr _______
	 2.	 Total	of	all	wages	paid	for	personal	services,	including	bonuses/commissions	...............	 $	_______________.____
	 3.	 Wages	in	excess	of	 	 	 	 	 	 (see	instructions)	...............................................................	 $<_______________.____
	 4.	 Out	of	state	wages		if	employee(s)	are	paid	in	multiple	states	(see	instructions)	...........	 $<_______________.____
	 5.	 Taxable	wages	(subtract	item	3	and	4	from	item	2,	enter	results	here)	...........................	 $________________.____
	 6.	 Contribution	rate	for	this	reporting	period	..........................................................................	 	 ____________________
	 7.	 Contribution	due	for	this	quarter	(multiply	item	5	by	 	 	 	 )	..........................................	 $________________.____
	 8.	 Amount	of	debit	or	credit	from	previous	quarters	.............................................................	                    $________________.____
	 9.	 Interest	(accrued	on	all	unpaid	contributions	at	the	rate	of	1.5%	per	month)	................	 $________________.____
	10.	 Penalty	(see	instructions)	.....................................................................................................	 $________________.____
	11.	 Total	amount	due	.................................................................................................................	 $________________.____
12.	 Amount	of	remittance	(make	payable	to	Arkansas	Department	of	Workforce	Services)	........ 	 $________________.____	
                                                                                                                                               CASHIER’S STAMP
                                      DO NOT ALTER THIS FORM
                                                                                              Initial
PART B.
                                      Enter the SSN, first name, middle initial, last name and
                                      total wages paid to each employee during the calendar
                                      quarter in the space provided below (continuation sheet Amt received
                                      provided).
                                      SOCIAL  SECURITY  NUMBER      FIRST  NAME,  MIDDLE  INITIAL  &  LAST  NAME  OF  EMPLOYEE               TOTAL  WAGES  PAID
                                  1	)                                                                                                    $                          .
                                  2	)                                                                                                    $                          .
                                  3	)                                                                                                    $                          .
                                  4	)                                                                                                    $                          .
                                  5	)                                                                                                    $                          .
                                  6	)                                                                                                    $                          .
                 ATTACH CHECK HERE
                                  7	)                                                                                                    $                          .
                                  8	)                                                                                                    $                          .
                                      PAGE ONE OF  _______  PAGE(S) TOTAL  NO.  OF  EMPLOYEES        TOTAL  WAGES  FOR  THIS  PAGE       $                          .
                                                                    ON  THIS  REPORT __________
                                      I  HEREBY  CERTIFY  THIS  REPORT  IS  TRUE  AND  CORRECT  AND  NO  PARTS  OF  THE  CONTRIBUTION  HAVE  OR  WILL  BE  BORNE  BY
                                      ANY  EMPLOYEE.
                                      SIGNATURE ______________________________TITLE __________________________ DATE _______________ TELEPHONE __________________
                                                                                                                                               DWS-ARK-209B
                                                                                                                                                     (REV.	01-09)
                                                                    MAINTAIN COPY FOR YOUR RECORDS

                              CONTINUATION SHEET FOR FORM 209B

     DWS	ID	Number	___________________________________	 	 Quarter	End	Date	_____________________
     Employer	____________________________________________________________
     Town	 	 _________________________________________	 	     	                          Page	________	of	________

     SOCIAL  SECURITY  NUMBER FIRST  NAME,  MIDDLE  INITIAL  &  LAST  NAME  OF  EMPLOYEE   TOTAL  WAGES  PAID
1	)                                                                                      $ .
2	)                                                                                      $ .
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                              TOTAL  WAGES  FOR  THIS  PAGE                              $ .

                                                                                           DWS-ARK-209C
                                                                                           (REV.	06-06)