DWS-LIC Utah Employer Quartely Wage List and Contribution Report Form 39 H Utah Department of Workforce Services, Unemployment Insurance REV 05/2010 140 E. 300 S, PO BOX 45233, Salt Lake City UT 84145-0233 1-801-626-9235 option S: 1-800-222-2857 option 5 The preferred method of filling this report is on-line at our website; http:W/ jobs.utah.gov Registration #: Instructions on Back FEIN: EMPLOYER NAME & ADDRESS: FEIN change A report must be filled even if Quarter no wages are paid for the quarter, See Instructions Qir End Date: Due Date: 1/15/2017 Number of Employees this quarter: fat Month 2nd Month 3rd Month Type or machine print preferred. Employee Social Security Employee Name First Middle Intial Last Total Wages Paid to Number Employes for this Otr 511-22-3333 Anthony Chinson 505-33-1775 Mark Wayland 047-68-8951 Sylvia Poppinico 022-68-1131 Slevon Varden 311-22-6694 Leonard Hissop 565-65-5655 Student F Success