2327 L Street, Sacramento, CA 95816-5014

916.440.1985 • FAX 916.440.1986 • [email protected] • www.capta.org

EVERY UNIT, COUNCIL AND DISTRICT PTA MUST COMPLETE AND RETURN THIS FORM EVEN IF NO ONE WAS PAID

WORkERS’ COMPENSATION ANNUAL PAYROLL REPORT (Attach insurance premium payment to Report and forward to council/district PTA as directed by their due date. Payment must be received from district PTA on or before January 31.)

Name of PTA ____________________________________________________________ District PTA ____________________ Address ________________________________________________________________ Council

______________________

City ____________________________________________________________________ Zip __________________________ Please note: List only those employees that PTA pays directly. Attach copies of all DE-6 and DE-542. Do NOT list when monies are donated to school district for employee salaries. Do NOT list company name, only individual names.

NAME OF WORkER

TYPE OF WORk BE SPECIFIC

DOES PERSON PAID CARRY HIS/HER OWN WORkERS' COMPENSATION INSURANCE? YES*

NO

DATES WORkED JAN 5, ____ TO JAN 4, ____

PAYROLL AMOUNT PAID

1 2 3 4 5 6 7 8 9 10 11 12 A

Total Payroll for ALL Employees

B

Less $1000

C

Gross Payroll

D

Premium due for additional Workers’ Compensation insurance coverage. ____% of Gross Payroll (Line C)

- $1,000.00

*If yes, worker must supply the PTA with a Certificate of Insurance from his/her Workers’ Compensation insurance carrier. This report form must be completed and forwarded through channels to reach the California State PTA office no later than January 31. • Unit, council and district PTAs are required to file this form, even if no one was paid. • Report ALL paid workers – attach additional Payroll Report detail pages(s) as necessary. • Attach copies of quarterly employee reporting forms DE-6 and DE-542 for Independent Contractors. • Write “NO ONE PAID” across form if no one was paid. • Signed by treasurer or president. • Forward through channels (unit to council to district). DO NOT send directly to the California State PTA office. • See California State PTA Toolkit, “Workers’ Compensation Annual Report,” 5.3.3i for more information. Date _______________________________________________________

Signed _______________________________________________________

Telephone (_______) __________________________________________

Position ______________________________________________________

356

California State PTA Toolkit – 2011

Worker's Compensation Annual Payroll Report.pdf

COMPENSATION INSURANCE? DATES WORkED PAYROLL. AMOUNT PAID. YES* NO JAN 5, ____ TO. JAN 4, ____. 356 California State PTA Toolkit – 2011.

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