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
                                                                                        SEASONAL
                                                                                                           DWS ID NUMBER
                                                                                                           DATE QUARTER ENDED
                                                                                                           FEDERAL ID NUMBER
                                                                                                           SEASONAL CODE
                                                                                                           SEASONAL DATES
                                                                                                           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, rst 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).
                                                                                                                        WAGES	PAID                         WAGES	PAID
                                  SOCIAL  SECURITY  NO. FIRST  NAME,  INITIAL  &  LAST  NAME  OF  EMPLOYEE              IN	SEASON                        OUT	OF	SEASON

  1	)                                                                                                           $               .                                 .
  2	)                                                                                                           $               .                                 .
  3	)                                                                                                           $               .                                 .
  4	)                                                                                                           $               .                                 .
  5	)                                                                                                           $               .                                 .
  6	)                                                                                                           $               .                                 .
                 ATTACH CHECK HERE
  7	)                                                                                                           $               .                                 .
  8	)                                                                                                           $               .                                 .
                                                                               TOTAL      WAGES FOR  THIS  PAGE $               .                                 .
                                  PAGE ONE OF  _______  PAGE(S)   TOTAL NO. OF  EMPLOYEES
                                                                  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-209BS
                                                                                                                                                           (REV.	01-09)
                                                                        MAINTAIN COPY FOR YOUR RECORDS

                                 CONTINUATION SHEET FOR FORM 209BS

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

                                                                                WAGES PAID      WAGES PAID
     SOCIAL  SECURITY  NO. FIRST  NAME,  INITIAL  &  LAST  NAME  OF  EMPLOYEE   IN SEASON       OUT OF SEASON

1 )                                                                           $  .              .
2 )                                                                           $  .              .
3 )                                                                           $  .              .
4 )                                                                           $  .              .
5 )                                                                           $  .              .
6 )                                                                           $  .              .
7 )                                                                           $  .              .
8 )                                                                           $  .              .
9 )                                                                           $  .              .
10 )                                                                          $  .              .
11 )                                                                          $  .              .
12 )                                                                          $  .              .
13 )                                                                          $  .              .
14 )                                                                          $  .              .
15 )                                                                          $  .              .
16 )                                                                          $  .              .
17 )                                                                          $  .              .
18 )                                                                          $  .              .
19 )                                                                          $  .              .
20 )                                                                          $  .              .
21 )                                                                          $  .              .
22 )                                                                          $  .              .
23 )                                                                          $  .              .
24 )                                                                          $  .              .
25 )                                                                          $  .              .

                                 TOTAL  WAGES  FOR  THIS  PAGE                $  .              .

                                                                                                DWS-ARK-209CS
                                                                                                (REV. 01-09)