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SCHEDULE A - EMPLOYER'S REPORT OF WAGES PAID TO EACH EMPLOYEE
For quarter ending December 31, 2000
RATE Your City Name FED ID 71-1234567
3.10 811 North Main Street STATE ID 501-5555
Harrison, AR 72601 STATE Arkansas
TOTAL WAGES EXCESS WAGES TAXABLE
SS NUMBER NAME FOR QUARTER OVER $ 7500.00 WAGES
----------- -------------------------- ----------- ------------ -------
987-65-4321 John Brown 400.00 400.00 .00
333-12-4447 Mary Smith 950.80 950.80 .00
499-83-7514 Bill White 824.00 .00 824.00
382-16-9004 John Williams 964.20 .00 964.20
997-12-8430 Tracy Snow 960.00 .00 960.00
----------- ----------- ---------
EMPLOYEES ON THIS PAGE: 5 PAGE TOTALS 4,099.00 1,350.80 2,748.20
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