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MISSOURI
DIVISION OF EMPLOYMENT SECURITY 2. MISSOURI EMPLOYER ACCOUNT NO. AUDIT BLOCK
QUARTERLY CONTRIBUTION AND WAGE REPORT (DO NOT USE)
3. CALENDAR QUARTER Date
Paid
YOU MAY FILE THIS REPORT BEGINNING
ON THE SECOND BUSINESS DAY AFTER THE * MUST HAVE AMOUNT IN 4, 5, & 6 EVEN IF ZERO
QUARTER ENDS AT: www.ustar.dolir.mo.gov *4. TOTAL WAGES PAID
1. EMPLOYER NAME AND ADDRESS *5. WAGES PAID IN EXCESS
OF
PER WORKER PER YEAR
(See instruction sheet)
*6. TAXABLE WAGES
Item 4 Minus Item 5
7. CONTRIBUTIONS DUE Due
Multiply Item 6 by Your
RATE Pd
8. INTEREST ASSESSMENT DUE Over
TO FEDERAL ADVANCES Under
15. FEDERAL ID NUMBER 9. INTEREST CHARGES Adj/Cr.
RETURN THIS PAGE WITH REMITTANCE TO: PER MONTH Applied
DIVISION OF EMPLOYMENT SECURITY If Paid After
PO BOX 888 10. LATE REPORT PENALTY
JEFFERSON CITY MO 65102-0888 CHARGES
(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) (See middle block
to the left)
THIS REPORT IS DUE BY 11. OUTSTANDING AMOUNTS AS
GREATER OF 10% OR $100 PENALTY AFTER OF
GREATER OF 20% OR $200 PENALTY AFTER 12. AUTOMATION SURCHARGE
Place X in applicable box and complete "Report on Change of
Business Operations" on the reverse side of the instruction sheet.
We have sold our business.
We have ceased employment. 13. TOTAL PAYMENT
We have an address change.
Please Print 14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR
RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH
NAME
TITLE 1st 2nd 3rd
S
SS NO. PHONE NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER (PRINT)
T
I certify that the information contained in this report, NAME PHONE
A including name and address in Item 1 is true and correct.
ADDRESS
P
16. Social Security NumberFirst Middle 17. Worker Name (Last Name) 18. Total Wages Paid This Quarter 19. Probationary
InitialInitial
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20. PAGE 1 OF PAGES TOTAL THIS PAGE MODES-4-7 (11-08) AI
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THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

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MISSOURI
DIVISION OF EMPLOYMENT SECURITY 2. MISSOURI EMPLOYER ACCOUNT NO.
QUARTERLY CONTRIBUTION AND WAGE REPORT
3. CALENDAR QUARTER
YOU MAY FILE THIS REPORT BEGINNING
ON THE SECOND BUSINESS DAY AFTER THE * MUST HAVE AMOUNT IN 4, 5, & 6 EVEN IF ZERO
QUARTER ENDS AT: www.ustar.dolir.mo.gov *4. TOTAL WAGES PAID RETURN
ORIGINAL
1. EMPLOYER NAME AND ADDRESS *5. WAGES PAID IN EXCESS WITH ANY
REMITTANCE
OFPER WORKER PER YEAR DUE
(See instruction sheet)
*6. TAXABLE WAGES
Item 4 Minus Item 5
7. CONTRIBUTIONS DUE
Multiply Item 6 by Your
RATE
8. INTEREST ASSESSMENT DUE
TO FEDERAL ADVANCES EMPLOYER'S
15. FEDERAL ID NUMBER 9. INTEREST CHARGES COPY
RETURN THIS PAGE WITH REMITTANCE TO: PER MONTH
DIVISION OF EMPLOYMENT SECURITY If Paid After
PO BOX 888 10. LATE REPORT PENALTY
JEFFERSON CITY MO 65102-0888 CHARGES
(MAKE CHECK PAYABLE TO DIVISION OF EMPLOYMENT SECURITY) (See middle block
to the left)
THIS REPORT IS DUE BY 11. OUTSTANDING AMOUNTS AS
RETAIN
GREATER OF 10% OR $100 PENALTY AFTER OF FOR
GREATER OF 20% OR $200 PENALTY AFTER 12. AUTOMATION SURCHARGE YOUR
RECORDS
Place X in applicable box and complete "Report on Change of
Business Operations" on the reverse side of the instruction sheet.
We have sold our business.
We have ceased employment. 13. TOTAL PAYMENT
We have an address change.
Please Print 14. FOR EACH MONTH, ENTER THE NUMBER OF COVERED WORKERS WHO WORKED OR
RECEIVED PAY FOR THE PERIOD WHICH INCLUDES THE 12TH OF THE MONTH
NAME
TITLE 1st 2nd 3rd
S
SS NO. PHONE NAME AND ADDRESS OF PREPARER IF OTHER THAN TAXPAYER (PRINT)
T
I certify that the information contained in this report, NAME PHONE
A including name and address in Item 1 is true and correct.
ADDRESS
P
16. Social Security NumberFirst Middle 17. Worker Name (Last Name) 18. Total Wages Paid This Quarter19. Probationary
InitialInitial
L
E

C
H
E
C
K

H
E
R
E

20. PAGE 1 OF PAGES TOTAL THIS PAGE MODES-4-9 (11-08) AI
IHE
THIS FORM IS READ BY A MACHINE, PLEASE TYPE OR PRINT THIS REPORT.

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        MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
        DIVISION OF EMPLOYMENT SECURITY                                                                                 P.O. Box 888
        Missouri Quarterly Wage Report                                                 Jefferson City, MO 65102-0888
        CONTINUATION SHEET
Print in this space employer's name and account number as shown onCalendar Quarter/Year
Form MODES-4 Missouri Quarterly Contribution and Wage Report

        16. Social Security NumberFirst     Middle 17. Worker Name (Last Name)         18. Total Wages Paid This Quarter       19. Probationary
                                  Initial   Initial

20. PAGE     OFOF                 PAGESPAGES                      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.
                                                                                       MODES-10B (12-07)  AI
                                                                                                                               Cont.

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