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F212 055 000 PDF results

f212-055-000 workers' compensation employer's quarterly report

Policyholder workers' compensation employer's quarterly report wa uni˜ed business identi˜er (ubi): l&i account id: due date: report is fo rquarte :

f212-239-000 instructions for completing the quarterly report

* use with form f212- 055-000 use the late payment worksheet on and interest instructions. step important: if your business currently has optional workers'...

Sample only not for use

f212-055-000 qr 9/05signature - information report prepared by (print name) preparer's telephone number official position ideclare under the penalty of perjury of...

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