Fillable Request for Verification of Credit Information Shown on Form 940 Form 940-B May 2010

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Request for Verification of Credit Information Shown on Form 940 Form 940-B May 2010

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Form 940-B
(Rev. May 2010)
Department of the Treasury - Internal Revenue Service
Request for Verification of
Credit Information Shown on Form 940
Name and address of employer
Date
Calendar year
Employer identification number
The Form 940 filed with the IRS by the employer named above indicates the following information for the calendar year shown.
State in Which
Employees Performed
Services
State Reporting No.
as Shown on
Employer's State
Contribution Returns
Taxable Payroll
(as defined in State Act)
Experience Rate
Period
(4)
(5)
Experience
Rate
(6)
Contributions
Actually Paid
to State
(1)
(2)
(3)
From- To-
State Agency: Please complete the certification below and fax or mail it back to us. Show any differences between the information shown above
and your records in the space below. Also show any contributions paid after February 1.
Fax Number:
Attention:
(FUTA Liaison)
OR
Mail to:
Director, Internal Revenue Service Center
Other
(remarks, etc):
State Reporting No.
as Shown on
Employer's State
Contribution Returns
Experience Rate
Period
State Taxable
Wages
Experience
Rate
Contributions
Paid Before
February 1
Contributions
Paid February 1
through
February 10
Contributions
Paid After
February 10
From- To-
I certify that, except as shown above, the records of this office agree with the entries shown in columns (2), (3), (4), (5), and (6), and that all
contributions were paid before February 1.
Name of State Name of State Officer
Date
Part 1-State Agency copy Cat. No. 20910X Form 940-B (Rev. 5-2010)
dd mmm yyyy
dd mmm yyyy
Cat. No. 20910X
Form 940-B
(Rev. May 2010)
Department of the Treasury - Internal Revenue Service
Request for Verification of
Credit Information Shown on Form 940
Name and address of employer
Date
Calendar year
Employer identification number
The Form 940 filed with the IRS by the employer named above indicates the following information for the calendar year shown.
State in Which
Employees Performed
Services
State Reporting No.
as Shown on
Employer's State
Contribution Returns
Taxable Payroll
(as defined in State Act)
Experience Rate
Period
(4)
(5)
Experience
Rate
(6)
Contributions
Actually Paid
to State
(1)
(2)
(3)
From- To-
State Agency: Please complete the certification below and fax or mail it back to us. Show any differences between the information shown above
and your records in the space below. Also show any contributions paid after February 1.
Fax Number:
Attention:
(FUTA Liaison)
OR
Mail to:
Director, Internal Revenue Service Center
Other
(remarks, etc):
State Reporting No.
as Shown on
Employer's State
Contribution Returns
Experience Rate
Period
State Taxable
Wages
Experience
Rate
Contributions
Paid Before
February 1
Contributions
Paid February 1
through
February 10
Contributions
Paid After
February 10
From- To-
I certify that, except as shown above, the records of this office agree with the entries shown in columns (2), (3), (4), (5), and (6), and that all
contributions were paid before February 1.
Name of State Name of State Officer
Date
Part -6XVSHQVH&DVHILOH copy Form 940-B (Rev. -2010)
dd mmm yyyy
dd mmm yyyy
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Request for Verification of Credit Information Shown on Form 940 Form 940-B May 2010

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Completed 23 May 2019

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