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Get and Sign Form Lb 0456 2011-2022
INSURANCE
QTRlYEAR
STATE ACCOUNT NUMBER
DATE DUE
QTR END DATE
FEDERAL ID NUMBER
Number of covered workers who worked during or received pay for the
payroll period which includes the 12th of the month
1st month
2nd month
RATE
ADD'L FEE
FOR OFFICE USE ONLY
DR
3rd month
TC
If typed, disregard vertical bars and type a consecutive string of characters, without commas, hyphens, or dollar signs, left justified, with
decimal in monetary amount. For proper alignment, center Total Wages...
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