HEALTH INSURANCE CONTRIBUTION Division of Unemployment Assistance Telephone (617) 626-5060 HEALTH INSURANCE 5th Floor 19 Staniford Street Boston, MA 02114-2589 QUARTER ENDING: DISCREPANCY NOTICE DUE: EMPLOYER NO: NAME/ADDRESS: DATE: DUA USE ONLY A AS REPORTED B AS CORRECTED C INCREASE D DECREASE GROSS WAGES LESS: EXCESS WAGES TOTAL TAXABLE WAGES CONTRIBUTION RATE CONTRIBUTION DUE CONTRIBUTION PAID 1. ADDITIONAL CONTRIBUTION DUE CONTRIBUTION INTEREST DUE 2. CONTRIBUTION INTEREST DUE 3. ADDITIONAL CONTRIBUTION AMOUNT DUE (1 + 2) 4. PENALTY DUE 5. AMOUNT DUE (3 + 4) = 7. TOTAL OVERPAID CONTRIBUTION INTEREST PAID 6. OVERPAID CONTRIBUTION PENALTY DUE PENALTY PAID NET TOTAL ENTER FOR EACH MONTH, ENTER THE NUMBER OF COVERED EMPLOYEES WHO WORKED DURING OR RECEIVED PAY FOR THE PAYROLL PERIOD WHICH INCLUDES THE 12 OF EMPLOYEE COUNT THE MONTH. IF NO EMPLOYMENT IN THE PAYROLL PERIOD, ENTER ZERO. 1ST MONTH 2ND MONTH 3RD MONTH REASON: CERTIFICATE (MUST BE EXECUTED) I Certify the information in this report is true and correct to the best of my knowledge and belief, that the wages reported represent all the wages paid during this quarter for employment by the Law, and that no part of the contribution reported was, or is to be deducted from workers’ wages. THIS STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. Signed this day of 20 REPORT MUST BE SIGNED Name: Title: Phone# THIS FORM IS TO BE USED ONLY FOR CORRECTING REPORT PREVIOUSLY SUBMITTED. Commonwealth of Massachusetts 1711-HI 03-06 American LegalNet, Inc. www.USCourtForms.com Telephone (617) 626-5060 HEALTH INSURANCE CONTRIBUTION DISCREPANCY NOTICE INSTRUCTIONS TO EMPLOYER - PLEASE READ CAREFULLY A. Enter the figures in Column A that you reported to the quarter. B. If the figures reported are CORRECT, but you have UNDERPAID your Contribution Due, enter the difference between Contribution Due and the amount of Contribution Paid in ltem 1. C. Underpayments of Contribution carry interest at the rate indicated on the face of this form from the due date of the original report until the date paid. Compute interest on additional Contribution Due and enter in Item 2. Do not enter interest if less than one dollar. D. Add Items 1 and 2 and enter in Item 3. Add penalty amount due in Item 4. Add Item 3 and Item 4 and enter in Item 5. This should be the total amount you have to pay with the return copy of this report. Make Check Payable To: Massachusetts Division of Unemployment Assistance E. If the figures reported are CORRECT but you OVERPAID your Contribution Due, enter the amount of overpayment from Item 6. Also enter in Item 7. F. If the figures reported are INCORRECT, enter correct figures in Column B. Compute the change from Column A and enter in Column C or D, as appropriate. G. If recomputation results in an INCREASE in Contribution Due, deduct Amount of Contribution Paid from Corrected Contribution Due and enter in Item 1. Follow instructions in numbers C and F above. H. If recommendation results in a DECREASE in Contribution Due, deduct corrected Contribution Due from Amount of Contribution Paid and enter in Item 6 and also enter in Item 7. I. EMPLOYEE COUNT. For each month listed, enter the number of all full-time and part-time employees in covered employment (subject to the Massachusetts Employment and Training Law) who performed services during the payroll period which includes the 12th of the month. If no employment in the payroll period, enter zero. J. Certificate (Must Be Executed). In the case of a corporation or association, it must be signed by the president, secretary, or an officer exercising a corresponding function, and in the case of a partnership or proprietorship, by a partner or the proprietor. Reports not certified will not be accepted. K. Call (617) 626-5060 for assistance, if necessary. OVERPAID AMOUNTS WILL BE APPLIED TO PAST OR FUTURE DEBT. Form 1711-HI (Back) American LegalNet, Inc. www.USCourtForms.com