This form contains 30 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Contact Information
Phone Number Text
Enter the phone number of the person signing the form. Maximum length is 8 digits.
Max length: 8 characters
Declaration
Signature Signature
Provide the signature of the person authorized to submit this form.
Title (Owner, Accountant, Preparer, etc.) Text
Enter the title of the person signing the form (e.g., Owner, Accountant, Preparer).
Signed Date (mm/dd/yyyy) Text
Enter the date when the form is signed in the format mm/dd/yyyy.
Employer Information
Employer Account Number Text
Enter your Employer Account Number. This is a unique identifier assigned to your business.
Max length: 10 characters
EFFECTIVE DATE (mmddyyyy) Text
Enter the effective date in the format MMDDYYYY.
Max length: 6 characters
FEIN Text
Enter your Federal Employer Identification Number (FEIN).
Additional FEINS Text
Enter any additional Federal Employer Identification Numbers (FEINs) if applicable.
Additional FEINS 2 Text
Enter any additional Federal Employer Identification Numbers (FEINs) if applicable.
Financial Information
Subtotal Text
Enter the subtotal amount of wages and contributions before any deductions.
Less Text
Enter the amount to be deducted from the subtotal, if any.
Total Text
Enter the total amount of wages and contributions after deductions.
Reporting Period
Quarter Ended Date Text
Enter the date when the quarter ended. This is the last day of the quarter for which you are reporting.
Due Date Text
Enter the due date for submitting this form. This is the deadline by which the form must be filed.
DELINQUENT IF NOT POSTMARKED OR RECEIVED BY Text
Enter the date by which the form must be postmarked or received to avoid delinquency.
Year Text
Enter the last two digits of the year for which you are reporting.
Max length: 2 characters
Quarter Text
Enter the quarter number (1, 2, 3, or 4) for which you are reporting.
Special Conditions
NO WAGES PAID THIS QUARTER CheckBox
Check this box if no wages were paid during this quarter.
OUT OF BUSINESS/NO EMPLOYEES CheckBox
Check this box if your business is out of operation or if you have no employees.
OUT OF BUSINESS DATE (mmddyyyy) Text
Enter the date your business went out of operation in the format MMDDYYYY.
Max length: 8 characters
Tax Rates and Contributions
(D1) U1 Rate Text
Enter the Unemployment Insurance (UI) rate for the quarter.
(D2) U1 TAXABLE WAGES FOR THE QUATER Text
Enter the UI taxable wages for the quarter.
(D3) UI CONTRIBUTIONS Text
Enter the UI contributions for the quarter.
(E1) ETT Rate Text
Enter the Employment Training Tax (ETT) rate for the quarter.
(E2) ETT CONTRIBUTIONS Text
Enter the ETT contributions for the quarter.
F1 Text
Enter the F1 value as required.
(F2) SDI TAXABLE WAGES FOR THE QUARTER Text
Enter the State Disability Insurance (SDI) taxable wages for the quarter.
(F3) SDI EMPLOYEE CONTRIBUTIONS WITHHELD Text
Enter the SDI employee contributions withheld for the quarter.
CALIFORNIA PERSONAL INCOME TAX (PIT) WITHHELD Text
Enter the California Personal Income Tax (PIT) withheld for the quarter.
Wage Reporting
Total Subject Wages Text
Enter the total subject wages paid to employees during the quarter.