MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                                                            EAU 10B 
             DIVISION OF EMPLOYMENT SECURITY 
                                                                                                                                              P.O. Box 888 
             QUARTERLY WAGE REPORT                                                                               Jefferson City, MO 65102-0888                     
             CONTINUATION SHEET 
                                                             Type or print in ink. 
Print employer’s name and account number as shown on                         CALENDAR QUARTER AND YEAR 
Form MODES-4 Quarterly Contribution and Wage Report 
                                                                             1st         2nd             3rd                            4th 

                                                                                                      Year 
                                                                                                  19.  20. 
16.Social Security No. 17.First Name                 Middle  Last Name             18.Total Wages Multi-  Proba- Probationary                 Probationary 
                                                     Initial                                      State  tionary                  Start Date  End Date 

21. PAGE ________ OF __________ PAGES                        TOTAL THIS PAGE 

                       Be sure that each page carries employer’s name, account number, page number, and calendar quarter and year. 
             Return the original completed form to the Division of Employment Security, P.O. Box 888, Jefferson City, MO 65102-0888. 
                                                             Retain copy for your file. 

             IMPORTANT: If needed, call 573-751-1995 for assistance in the translation and understanding of the information in this document. 
¡IMPORTANTE!: Si es necesario, llame al 573-751-1995 para asistencia en la traducción y entendimiento de la información en este documento. 
                       Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services 
                       are available upon request to individuals with disabilities.   TDD/TTY: 800-735-2966   Relay Missouri: 711 
                                                                                                                                             MODES-10B (11-19)  AI 
                                                                                                                                              UITax