Form Modes-4a - Contribution & Wage Adjustment Report For Quarter Ending - 2011
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1MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
EAU ADJX
DIVISION OF EMPLOYMENT SECURITY
CASE ID
P.O. Box 59, Jefferson City, MO 65104-0059
CONTRIBUTION & WAGE ADJUSTMENT REPORT FOR QUARTER ENDING
Adjustments may be submitted online at by registering with the password printed on the quarterly report.
STATUTE OF LIMITATIONS
A claim for refund or credit must be filed within three years of the due date of the quarter being adjusted.
1. Employer Name and Address
2. Missouri Employer Account Number
3. Contribution Rate
4. Reason for Claiming Adjustment
Note: Adjustment will not be accepted if this portion is not completed.
A.
B.
C.
Audit Block
Previously Reported
Correct
Difference - Over or
AGENCY USE
for Quarter
Totals
Under-Reported
ONLY
5. Total Wages Paid
6. Wages in Excess of $
7. Taxable Wages
8. Contributions Due
9. Interest Due
10. Total Payment Due
11. Additional Amounts Due
12. Credit Due
Enter below ONLY those employees whose wages or social security number are being corrected.
NOTE: If you are adjusting more than five (5) employees, list the items on a separate page with the same format, including employer
name and account number.
13.
Worker's
14.
Worker's Name
Total Wages Paid
Audit Block
Social Security
15.
As
16.
As
AGENCY USE
First
Middle
Number
Initial
Initial
Last
Reported
Corrected
ONLY
17. TOTALS
18. DIFFERENCES ( + or - )
I certify that the foregoing information is true and correct.
19. Signature
Date
Phone Number (Area Code)
Title
(READ FOLLOWING INSTRUCTIONS)
MODES-4A (08-11) AI
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