MISSOURIDIV.OFEMPLOYMENTSECURITY
              UNEMPLOYMENTINSURANCETAX
              573-751-1995

              QUARTERLYCONTRIBUTION                            2.MOEMPLOYERACCOUNTNO.          YEAR                   AUDIT
              ANDWAGEREPORT                                                                                           (DONOT
Fileonlineatuinteract.labor.mo.gov           EAU4                                                                     USE)
                                                               3.CALENDARQUARTER                                      DatePaid
1.EMPLOYERNAMEANDADDRESS                                       1st        2nd              3rd      4th

                                                                    MUSTHAVEAMOUNTSIN4,5,&6,EVENIFZERO
                                                               4.TOTALWAGESPAID
                                                               5.WAGESPAIDINEXCESSOF
                                                                          PERWORKER
                                                               PERYEAR(SeeInstructionSheet)
                                                               6.TAXABLEWAGES
                                                               (Item4MinusItem5)
                                                               7.TAXESDUE(MultiplyItem6
                                                               byYourRate)
14.FEDERALIDNUMBER_____________________________________        8.INTERESTASSESSMENTDUE
                                                               TOFEDERALADVANCES
Ifmailing,returnthispagewithremittanceto:
              Divisionof Employment Security                   9.INTERESTCHARGESOF
                                                                      PERMONTHIF
                    P.O.Box888                                 PAIDAFTER
              JeffersonCity,MO65102-0888
MakecheckpayabletoDivisionofEmployment Security                10.LATEREPORTPENALTY
orpayonlineat uinteract.labor.mo.gov                           CHARGES(SeeItem15totheLeft)
15.THISREPORTISDUEBY                                           11.OUTSTANDINGAMOUNTS
GREATEROF10%OR$100PENALTYAFTER                                 ASOF
GREATEROF20%OR$200PENALTYAFTER                                 12.TOTALPAYMENT
PlaceXinapplicableboxandcomplete“EmployerChangeRequest.”
                                                               13.FOREACHMONTH,ENTERTHENUMBEROFCOVEREDWORKERS
        Business          Employment         Changeof          WHOWORKEDORRECEIVEDPAYFORTHEPERIODTHATINCLUDES
        Sold              Ceased             Address           THE12THOFTHEMONTH.
(PleasePrint) Icertifythattheinformationcontainedinthisreport, 1st                  2nd             3rd
includingnameandaddressinItem1,istrueandcorrect.
TAXPAYER
ORPREPARER_______________________________________________TITLE___________________________________PHONE_____________________
16.                       17.                                                   18.        19.      20.Probationary
                          First          Middle                Last          Total         Multi-   Check Start       End
SSN                       Name           Initial               Name       Wages            state    IfYes Date        Date

21.PAGE OF    PAGES                                     TOTALTHISPAGE                                     MODES-4(0 -1 )  1 9  
                                                                                                                      UITax
                          THISFORMISREADBYAMACHINE. PLEASETYPEORPRINTTHISREPORT.
                    MissouriDivisionofEmploymentSecurityisanequalopportunityemployer/program.Auxiliaryaidsandservices
                          areavailableuponrequesttoindividualswithdisabilities. TDD/TTY:800-735-2966 RelayMissouri:711