EIN 	Name Control	Business Name 1	Business Name 2	Address 1	Address 2	City	State	Zip Code	Agent Name	Agent Title	Contact Name	Contact Title	Phone Number	e-Mail Address	Signature Name	Signature Date	Account Type	Routing Number	Account Number	Online PIN (For Indirect Filers Only)	PTIN	Year of Return (YYYY)	"Single State Filer (Yes for Single State, No for Multi State)"	Is ANY your FUTA tax excluded from State Unemployment Tax? (Y for Yes or N for No)	Is ALL of your FUTA tax excluded from State unemployment Tax? (Y for Yes or N for No)	"Final Return (Y for Yes, N for No)"	"No Payments (Y for Yes, N for No)"	Total Payments (Currency)	State Contributions Paid on Time (All States) (Currency)	State Contributions Paid Late (All States) (Currency)	Payments Exempt from FUTA Tax (Currency)	"Fringe Benefits (Y for Yes, N or Blank for No)"	"Group Term Life Insurance ( Y for Yes, N or Blank for No)"	"Retirement/Pension (Y for Yes, N or Blank for No)"	"Dependent Care (Y for Yes, N or Blank for No)"	"Other ( Y for Yes, N or Blank for No)"	Refund or Apply Overpayment (R for Refund and A for Apply)	"Payments for Services ($7,000 or Higher) (Currency)"	Line 7a wages paid before 7/1/2011 (Currency)	Line 7a FUTA wages paid after 6/30/2011 (Currency)	Tax Deposits (Currency)	Quarter 1 Liability (Currency)	Quarter 2 Liability (Currency)	Quarter 3 Liability (Currency)	Quarter 4 Liability (Currency)	State Abbreviation 1  (Two Character Abbreviation)	BLANK	FUTA Taxable Payroll (Currency)	 BLANK 	State Abbreviation 2	BLANK	FUTA Taxable Payroll	 BLANK 	State Abbreviation 3	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 4	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 5	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 6	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 7	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 8	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 9	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 10	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 11	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 12	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 13	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 14	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 15	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 16	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 17	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 18	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 19	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 20	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 21	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 22	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 23	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 24	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 25	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 26	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 27	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 28	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 29	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 30	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 31	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 32	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 33	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 34	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 35	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 36	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 36	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 37	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 38	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 39	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 40	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 41	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 42	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 43	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 44	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 45	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 46	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 47	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 48	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 49	 BLANK 	FUTA Taxable Payroll	 BLANK 	State Abbreviation 50	 BLANK 	FUTA Taxable Payroll	 BLANK 
666666666	ELEC	Electric Corporation	Test International	242 Elm St.	Suite Z	Annapolis Junction	MD	20701	Tim Welch	Accountant	Tina Welch	Bookeeper	3015551212	tw@lswonline.com	Tim Welsh	4/1/2004						2011	N	N	N	N	N	"$25,000.00 "	$500.00 	$250.00 	$100.00 			Y			R	$200.00 			$500.00 	$125.00 	$125.00 	$125.00 	$131.40 	MI	 	"$25,000.00 "	   																																																																																																																																																																																																												
777777777	TEST	Testing Corporation	Storage Solutions	223 Misdemeanor Ave	Suite B	Rockville	MD	20654	Kenneth Sims	President	Brenda Willis	Financial Secretary	2402224544	bw@lswonline.com	Brenda Willis	3/1/2004	Checking	255071981	333333333			2011	N	N	N	Y	N	"$10,000.00 "	$300.00 	$0.00 	$0.00 	Y	Y				R	$200.00 			$600.00 	$50.00 	$50.00 	$50.00 	$47.60 	CA				AZ																																																																																																																																																																																																											
555555555	JOHN	Johnson Plumbing	Roto Rooter	21 History Road		Springdale	MD	20774	James Johnson	Owner	Jenny Wilson	Bookeeper	3013244929	jj@lswonline.com	James Johnson	3/15/2004						2011	Y	N	Y	N	N	"$1,000.00 "	$0.00 	$0.00 	$230.00 				Y		R	$400.00 			$30.00 	$6.00 	$6.00 	$6.00 	$4.94 	TX								 	  																																																																																																																																																																																																						
888888888	HENN	Henning Systems		393 Florida Ave		Silver Spring	MD	20601	Cynthia Henning	Owner	Sandra Bullock	Bookeeper	3018393209	sb@lswonline.com	Cynthia Henning	4/12/2004						2011	N	N	N	N	N	"$50,000.00 "	"$2,000.00 "	$250.00 	$0.00 						A	"$1,000.00 "			"$3,500.00 "	$203.00 	$203.00 	$203.00 	$204.00 	AL	 	"$40,000.00 "		GA	 	"$10,000.00 "