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

                                                                               REIMBURSABLE

                                                                                                           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.	 Penalty	(see	instructions)	.....................................................................................................	 $________________.____
	 4.	 Amount	of	remittance	(make	payable	to	Arkansas	Department	of	Workforce	Services)	........ 	 $________________.____	

                                                                                                                                           CASHIER’S STAMP
                                  DO NOT ALTER THIS FORM
                                                                                           Initial
PART B.
                                                                                           Amt received
                                  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  Penalty code
                                  provided).
                                  SOCIAL  SECURITY  NUMBER      FIRST  NAME,  MIDDLE  INITIAL  &  LAST  NAME  OF  EMPLOYEE               TOTAL  WAGES  PAID
  1	)                                                                                                                                $            .
  2	)                                                                                                                                $            .
  3	)                                                                                                                                $            .
  4	)                                                                                                                                $            .
  5	)                                                                                                                                $            .
  6	)                                                                                                                                $            .
  7	)                                                                                                                                $            .
  8	)                                                                                                                                $            .
                 ATTACH CHECK HERE
  9	)                                                                                                                                $            .
10	)                                                                                                                                 $            .
11	)                                                                                                                                 $            .
12	)                                                                                                                                 $            .
                                  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.

                                  SIGNATURE ______________________________TITLE __________________________ DATE _______________ TELEPHONE __________________

                                                                                                                                           DWS-ARK-209BR
                                                                                                                                           (REV.	06-06)
                                                                MAINTAIN COPY FOR YOUR RECORDS

                              CONTINUATION SHEET FOR FORM 209BR

     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 )                                                                                       $ .
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                              TOTAL  WAGES  FOR  THIS  PAGE                               $ .

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