2025 Printable Template
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Form last updated: 03/2024. Please verify this is the current version before use.
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Step 01
Determine if you are the employer or the third-party payer.
Step 02
Enter the filer's name, address, and contact details.
Step 03
Provide the other party's name and EIN if applicable.
Step 04
Fill in the sick pay and tax amounts in the designated fields.
Step 05
Check the corrected box if amending a previously submitted form.
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