SOCIAL SECURITY ADMINISTRATION

EMPLOYER DATA
Business' Name*
Employer Identification Number (EIN)*
CHECK TYPE OF BUSINESS*

CorporationSole ProprietorshipJoint VentureCredit UnionPartnershipOther
Owner's Name*

First NameLast Name
P. O. Box*
Location*
Hamlet, State
Phone*
Email
Payroll Ending Date*

MonthDayYear
Date
Date Quarter Ended*

MonthDayYear
Qtr ending date (01/31/XXXX, 04/30/XXXX, 06/30/XXXX, 12/31/XXXX)
Total Gross Revenue earned during this period*
Total Gross Revenue earned during this period*
EMPLOYEE(S) DATA
File Upload*

Upload Employee(s) data spreadsheet
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Total Number of Employees*
Total number of employees on the uploaded spreadsheet
SSA & HCF Taxable Amount*
Total Taxable/Gross wage for the quarter
Total SS Tax Due*
Total HCF Tax Due*
Grand Total Due*
AUTHORIZATION AND PAYMENT
IMPORTANT NOTICE: Failure to comply with the deodlines will result with civil penalty of 100% of amount owed or $250 which ever is greater. A civil penalty could be charged up to $2,000 per Quarter. 14. DECLARATION: Under the penalties of perjury, / declare that the Quarterly Tax Report is, to the best of my knowledge and belief, true and correct.

DECLARATION: Under the penalties of perjury, I declare that the Quarterly Tax Report is, to the best of my knowledge and belief, true and correct.
Title*
Owner's Name/Officer*
Date*

MonthDayYear
Date
To prevent spam, please do the math challenge. *

Total Amount Due

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

EMPLOYER DATA