Cash Remittance
Section 1: Employer Information
Employer Code:
Employer Name:
Submitter's Name:
Submitter's Phone Number:

( ) -

ext.
Section 2: Payment Method and Amount
  Check(s)
Total amount: $
Wire Transfer*
Date:
View Calendar

Total amount: $
ACH (Automated Clearing House)*
Date:
View Calendar

Total amount: $

* Complete a separate form for each wire transfer or ACH.