Spreadsheet: e32995ef-444f-4050-ad65-3e875f27ef6b
Sheet: Sheet1

Unnamed: 0 | DIOCESE OF MADISON | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
 | 702 SOUTH HIGH POINT ROAD, P.O. BOX 44983, MADISON, WI 53744-4983
 | WORKER'S COMPENSATION INSURANCE - PAYROLL AUDIT QUESTIONNAIRE
 | (For the 12-month period ending December 31, 2011)
 | Purpose:  To assure adequate future coverage and proper premium charges based upon actual payroll/census experience for the calendar year 2011.
 | Parish/School Name : |  |  |  |  | FEIN #:
 | Location:
 | Please also submit any tax forms submitted for payroll verification.  (941's - 1st Qtr 2011, 2nd Qtr 2011, 3rd Qtr 2011 & 4th Qtr 2011, OR annual 2011 940 Tax Form)
 | Please list the payrolls for your employees during the policy year based on the type of work performed. Do not duplicate any employees in any one section.  For Domestic Workers (class codes 0913 & 0908), we only need the # of employees, not the amount of salaries.
 | Permanent Religious (Priests, Brothers, Deacons & Sisters)
 |  | Paid under $12,000 |  |  |  | (8868) | # |  |  | $ |  | Gross Payroll
 |  | Paid over $12,000 |  |  |  | (8868) | # |  |  | $ |  | Gross Payroll
 | Church & School - Professional Employees and Clerical such as:
 | Substitute clergy, deacons, administrators/managers, teachers, coaches, music directors, organists, religious education, youth ministry, clerical, sacristans, bookkeepers, etc. |  |  |  |  | (8868) | # |  |  | $ |  | Gross Payroll (including Overtime)
 |  |  |  |  |  |  |  |  |  | $ |  | Overtime
 | Church & School - Non-Professional Employees such as: |  |  |  |  | (9101) | # |  |  | $ |  | Gross Payroll (including Overtime)
 | Maintenance, janitorial, cleaning personnel, groundskeepers, cafeteria workers, lunch room monitors, etc. DO NOT INCLUDE DOMESTIC WORKERS IN CLASS CODES 0913 & 0908 LISTED BELOW. |  |  |  |  |  |  |  |  | $ |  | Overtime
 | Bus Drivers - School & Church |  |  |  |  | (7380) | # |  |  | $ |  | Gross Payroll (including Overtime)
 |  |  |  |  |  |  |  |  |  | $ |  | Overtime
 | Cemetery Workers - All Employees (including Sales), Clerical & Management |  |  |  |  | (9220) | # |  |  | $ |  | Gross Payroll (including Overtime)
 |  |  |  |  |  |  |  |  |  | $ |  | Overtime
 | Domestic Workers - Full time (over 20 hours/week) Rectory housekeeper                                    DO NOT INCLUDE IN ANY OTHER CATEGORY! |  |  |  |  | (0913) | #
 | Domestic Workers - Part time (less than 20 hours/week) Rectory housekeeper                                DO NOT INCLUDE IN ANY OTHER CATEGORY! |  |  |  |  | (0908) | #
 | Other types of employees (specify type of work and salary) not shown above:
 |  |  |  |  |  | Total # of Employees & Payroll: | # | 0 |  | $ | 0
 | Please list the total number of employees and/or volunteers for the following classifications.  Include FT and PT employees.
 |  |  |  |  | Full-Time |  |  | Part-Time |  |  | TOTAL
 | Accountants/Bookkeepers/Cashiers: |  |  | # |  |  | # |  |  | #
 | Volunteers who handle cash (money counters, etc): |  |  | # |  |  | # |  |  | #
 | Day Care Providers (if applicable): |  |  | # |  |  | # |  |  | #
 | Completed by: |  |  |  |  | FEIN#:
 | E-mail address:
 | Date: |  |  |  |  | Signed:
 |  |  |  | If you do not have any payroll to report, please return form with note indicating this.
 |  |  | This report is due by February 27, 2012.  If you have questions, please call [NAME] at (608) 821-3027.