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ATE QUARTER ENDED FEDERAL ID NUMBER REPORT DUE DATE Check box and return if no wages paid c PART A. 1. 2. 3. 4. 5. 6. 7. 8. 9. 0. 1 1. 1 12. 1st mo 2nd mo 3rd mo Number of employees in the pay period including the 12th of: of qtr of qtr of qtr Total of all wages paid for personal services, including bonuses/commissions................ $ . Wages in excess of (see instru.

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