Application

Colorado Department of Labor and Employment

Unemployment Insurance Operations, Business Analysts

P.O. Box 8789, Denver, CO 80201-8789

303-318-9100 (Denver-metro area) or 1-800-480-8299 (outside the Denver-metro area)

APPLICATION TO REPLICATE THE TAX-AND-WAGE REPORT

The Colorado Department of Labor and Employment, Unemployment Insurance (UI) Operations, is accepting applications to replicate the tax and/or wage report. The tax report, wage report, or both the tax-and-wage reports may be replicated. If you are interested in replicating these forms, please follow the instructions on the reverse side. As the specifications for the tax-and-wage report have not yet been finalized, possible changes to form specifications will be communicated to participants during the testing process for those who are approved to develop replicated forms.

NOTE: Replicated forms must not be used until approved by UI Operations.

Name of Business or Employer Representative		Employer Account Number (if you are an employer)
Mailing Address Address 1 Address 2 CityStateZip		E-Mail Address
		Contact Name
		Contact Telephone Number
Interested in replicating Tax Report Wage Report Both Tax-and-Wage reports
Interested in replicating beginning with the report filed for		First Quarter (January 1 to March 310 Second Quarter (April 1 to June 1) Third Quarter (July 1 to September 30) Fourth Quarter (October 1 to December 31)
If you own a business, for how many employees do you report wage?
Current Method of filing		Form UITR-1, Unemployment Insurance Tax Report Form UITR-1a, Unemployment Insurance Report of Workers' Wages Magnetic Tape or Diskette Internet
If you own a business, does a tax-service group (TSG) or employer representative prepare and/or file your tax-and-wage report? Yes No
Are you a TSG or an employer representative? Yes No
If you are a TSG or an employer representative group, are you reporting wages for more than one company? Yes No If Yes, for how many companies do you prepare reports?
If you are an employer, do you file your tax-and-wage report on forms provided by a software vendor? Yes No
Does your company develop and sell software to businesses for filing their tax-and wage reports? Yes No
Name of Representative	E-mail Address of Representative	Date	Representative Telephone Number