MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 
                DIVISION OF EMPLOYMENT SECURITY 
                TRANSMITTAL OF QUARTERLY WAGES REPORTED ON MAGNETIC MEDIA 
                This form can be found online at www.labor.mo.gov/sites/default/files/pubs_forms/4260-AI.pdf              . 
                Alternatively, you may submit the quarterly report and wage data online at https://uinteract.labor.mo.gov. 
                When selecting a method to report the wage detail, select option ‘Method B’ to upload the wages from 
                one of the accepted file formats. 

       RETURN THIS FORM WITH MAGNETIC MEDIA AND                                             THE EXTERNAL LABEL ON 
 QUARTERLY CONTRIBUTION REPORT WITH REMITTANCE TO:                                          MEDIA MUST INCLUDE: 
                             Division of Employment Security                                       Account Number(s) 
                Attention: Employer Accounts Unit/Magnetic Media                                   Employer Name(s) 
                  P.O. Box 59, 421 E. Dunklin Street                                               Quarter/Year 
                             Jefferson City, MO  65104-0059                                        Record Length 
                                     573-751-3422                                                     File Name 

                **NOTE: It is not necessary to send the Contribution Report to the P.O. Box 59 address 
                                     and the magnetic media to the P.O. Box 888 address. 
 
 1. Employer Name                                                            2. Quarter               3. Year 
                                                                                                                  
 4. CD-RW Format  Record Length (accepted on Internet)           Number of CD-RW 5. Total Number of Employers Reported 
                              72                                                                   
                              275 (ICESA format only)                        
                                                                                 6. Total Number of Employees Reported 
                              512                                            
                                                                                                   
                              Excel                                          

                                              Employer Summary Information 
 7. Missouri Employer Account Number 8.      Number of            9. Missouri Employer Account Number  10.      Number of 
                                              Employees Reported                                       Employees Reported 
                                                                                                                                       
 Contact name (Please print)                                                     Date 
                                                                                                   
 Title                                                                           Phone Number 
                                                                                                   
               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-4260 (05-16)  AI 
                                                                                                                            UITax