Fillable Printable De 973
Fillable Printable De 973
De 973
DE 973B Rev. 1 (3-17) (INTERNET)Page 1 of 1CU
PAYROLL REPORTING AGENT REGISTRATION FORM
Please complete and return this Payroll Reporting Agent Registration Form,DE973B,if you will be
registering as a Payroll Reporting (P/R) Agent with the Employment Development Department.
Note: Thisrequest cannot be processed ifthe following informationis missing.
1.P
ayroll Reporting Agent Company Information:
Federal Identification Number:
1
Business Name:
Address:
2.Payroll Reporting Agent Contact Information:
Representative Name(Primary):
PhoneNumber:
FaxNumber:
Representative Name(Secondary):
PhoneNumber:
FaxNumber:
3.Total number of clients to date:
4.Will you be filing electronically?
Yes
No
Mail thiscompleted registration form andclient listing to:
A
ttention: Agent Desk
Employment Development Department
Account Services Group, MIC 13
PO Box 826880
Sacramento, CA 94280-0001
Fax Number: 916-654-9211
For additional information, contact the Agent Desk at 916-654-7263.
INTERNAL USE ONLY: PR AGENT CODE NO.:_______________
