Employer'S Wage Adjustment Report Form - Iowa Workforcedevelopment
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1Employer's Wage Adjustment Report
IOWA WORKFORCE DEVELOPMENT
TAX BUREAU, UIS DIVISION
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68-0061 (09-04)
Assignment A _________________
1000 E Grand Avenue
(For correcting quarterly Employer's Contribution and Payroll Report 65-5300)
Des Moines, IA 50319-0209
Page ______ of ______
This form is available at no cost to the public from Iowa Workforce Development.
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Employer Name
>
Iowa Account No. (6-digit)
>
Trade Name
>
Location Code (if Applicable)
>
Reason(s) for Adjustment >
(1)
Quarter And Year (Q/YY)
>
(A separate report must be prepared for each quarter)
SCHEDULE A:
PAYROLL LISTING CORRECTIONS -- LIST ONLY THOSE WORKERS WHOSE WAGES ARE TO BE CORRECTED
EMPLOYEE NAME
TOTAL WAGES
TAXABLE WAGES
RSN
Social Security Number
As Reported
CDE
Last Name
First Name
MI
Should Be
As Reported
Should Be
1
Page Totals >
Should Be (Col 2)
As Reported (Col 1)
SCHEDULE B: CORRECTION OF PAYMENT COMPUTATION
1. Total Wages
>
INSTRUCTIONS FOR LINES 1-5: Column 1 - COPY the figures previously
2. Taxable Wages >
reported on the same lines in the Payment Computation section of Employer's
3. State Exp Rate @
% >
Contribution & Payroll Report or, if this quarter has been previously adjusted
with this form, COPY from Schedule B, Col. 2 of that form. Column 2-Start with
4. Reserve Fund @
% >
Col. 1 figures and add or subtract the net wage increases or decreases
5. Surcharge @
% >
resulting from Sched. A adjustments. Recalculate State Experience,
6. State Experience Underpaid/(Overpaid) [Line 3, Col 2 - Col 1] >
Reserve Fund, & Surcharge using corrected Line 2 figure.
7. Reserve Fund Underpaid/(Overpaid)
[Line 4, Col 2 - Col 1] >
Taxable Wage Base
>
8. Surcharge Underpaid/(Overpaid)
[Line 5, Col 2 - Col 1] >
9. Subtotal Additional Due or (Total Credit)
[Line 6 + 7 + 8] >
Preparer's Signature/Name >
Preparer's Title
>
10. Interest Due [Line 9 X # Days Late X 0.000333] >
Preparer's Phone
>
11. Additional Penalty Due [Only if penalty on original filing] >
Date Signed
>
12. Total Additional Due
[Line 9 + 10 + 11] >
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
PHOTOCOPY BLANK FORM IF MORE ADJUSTMENTS ARE NEEDED. PLEASE ENCLOSE PAYMENT FOR TOTAL ADDITIONAL DUE.
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