Employer'S Wage Adjustment Report Development
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4Employer's Wage Adjustment Report
68-0061 (5-15)
Section 1
Section 2
Reason Codes For Adjustments
UI Account # :
1: Correct Reported Wages
FEIN:
2: Add Employee
3: Correct Social Security Number
Legal Business Name :
4:
Quarter/Year:
Reporting Unit :
Section 3: Adjustment to Reported Wage Detail
Employee Name
Total Wages
Taxable Wages
Social Security
Corrected Social
Reason
Amount
Amount
Number Reported
Security Number
Code
Previously
Corrected
Previously
Corrected
As
Only
Last, First, MI
Reported
Amount
Reported
Amount
Section 4: Adjustment to Wages & Contribution
Amount
Corrected
Totals As Reported on Original Report & Corrected Totals
Reported
Amount
Total Wages
Taxable Wages
State Experience Rate @
%
Contribution Overpaid/Underpaid
Interest Due
[Additional due x .0003333 (Rounded to two decimals) then take Daily Rate x # days late
]
Total Additional Due (Additional Penalty could apply if original report was late)
Total Amount Enclosed - Make Check Payable to Iowa Workforce Development
Section 5
Fax Completed Form to: 515-242-6301
OR
Authorized Signature:
Mail Completed Form to: Iowa Workforce Development
Unemployment Insurance Tax Bureau
Print Preparer's Name:
1000 E Grand Ave
Des Moines, IA 50319-0209
Preparer's Title:
Phone:
Questions: 1-888-848-7442 select option 3, then option 7
Date Submitted:
Equal Opportunity Employer/Program
Page
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