Example of UCT-14309-E, Reimbursable Employer Statement

Sample Form

Form Summary

1. Payment Remittance Coupon:
   • If you pay by check or money order, the top portion of this statement should be detached and returned with your payment to ensure proper crediting to your account. Payment instructions are listed on the back of the form under How to Pay. You can also pay on-line by accessing the web site listed on the back of the form.
   • Minimum Payment: If you have an approved installment agreement, the amount shown is the minimum payment due on this coupon.
   • Due Date: This is the due date for receipt of your payment. If it is not received by the due date, interest is assessed on the amount due. Beginning with August 2012, interest is assessed at .75% per month or 9% per year. Prior to August 2012, interest was assessed at 1% per month or 12% per year.
     
     
2. Account No.:
   • The account number listed on the “Payment Remittance Coupon” is the reimbursable employer UI account that all benefit charge, benefit adjustment, and payment activity is posted to.
     
     
3. Statement Period:
   • This is the time period (month) that the activity in your account covers.
     
     
4. Previous Balance:
   • This is the ending balance (either an amount due or an available (credit) balance from your previous month’s statement.
     
     
5. Benefit Charges:
   • This is the amount of unemployment benefit payments made to claimants that were charged to your account during the month. This should equal the total benefit charges shown below for each of the periods listed as Benefit Charges in the Description column.
     
     
6. Adjustments:
   • This is the net amount of all adjustments and payments you made that were posted to your account during the month. This should equal the net total for all items shown below as “Employer Payment” and “Benefit Adjustments” in the Description column. These items can either be a debit (increase in amount due) or a (credit) (decrease in amount due) to your account.
     
     
7. New Balance:
   • This is the balance in your account at the end of the month. This can either be an amount due or a (credit) balance.
     
     
8. Accounting Transaction Details:
   • This is a summary of the “Benefit Charges and Adjustments” statements you received during the month. Depending on the activity in your account, you could have received up to 4 statements during the month. This also shows any payments made that were received by us and posted to your account during the month.
     
     
9. Please pay:
   • If the “New Balance” amount is positive, this is the amount due by the date indicated.

Sample Form