SOCIAL SECURITY ADMINISTRATION

EMPLOYER DATA
Employer Identification Number (EIN)
Name of Employer
Employer's SSN
Phone
Format: (000) 000-0000.
Email
P. O. Box
Hamlet, State
Date Quarter Ended

MonthDayYear
2 digit month, 2 digit day, 4 digit yearQtr ending date (01/31/XXXX, 04/30/XXXX, 06/30/XXXX, 12/31/XXXX)
EMPLOYEE(S) DATA
Total Number of Employees
Total number of employees on the uploaded spreadsheet
SSA & HCF Taxable Amount
Total Taxable/Gross Wage Amount for the period
Total SSA Tax Amount Due
Total HCF Tax Amount Due
Grand Total Amount Due
File Upload

Upload Employee(s) data spreadsheet
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AUTHORIZATION AND PAYMENT
IMPORTANT NOTICE: Failure to comply with the deadlines 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.

DECLARATION: Under the penalties of perjury, / 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
2 digit month, 2 digit day, 4 digit yearDate
To prevent spam, please do the math challenge.

USD

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

PAYMENT REMINDER
By checking the box above, I consent to receive quarterly filing and payment reminder emails from ROPSSA at the email address provided.

Email reminders are provided as a courtesy and do not replace the employer/member's responsibility to timely file required quarterly reports, make any applicable payments by the due date, and comply with ROPSSA payment requirements.
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EMPLOYER DATA