Form Dllr/dui 21 Web - Request For Wage Adjustment

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Division of Unemployment Insurance
Accounts Receivable Unit – Room 415
1100 North Eutaw Street
Baltimore, MD 21201
1-800-492-5524 Ext. 2410
Local: 410-767-2410
Fax: 410-767-2680
Federal Number: ________ - __________________________
Request for Wage Adjustment
(A Separate Form Must Be Submitted For Each Quarter)
Gentlemen:
Request is hereby made for an adjustment to my account for the following reason(s): _________________________________________
_____________________________________________________________________________________________________________
AMOUNT OF REMITTANCE (If Applicable)
$
FOR THE QUARTER ENDING:
EMPLOYER ACCOUNT NUMBER:
00 _____________________________
ITEM
AMOUNT REPORTED
CORRECTED AMOUNT
DIFFERENCE (+ OR -)
Total Wages
Excess Wages
Taxable Wages
X Tax Rate
. __________
. __________
. __________
Contributions (Tax)
*Interest should be calculated at 1.5% per month from the quarterly due date.
INTEREST DUE
$
(Make your check payable to Maryland Unemployment Insurance Fund)
TOTAL
$
WAGE DETAIL
(If more space is needed, please send on additional blank sheets)
SOCIAL SECURITY
DIFFERENCE
EMPLOYEE NAME
AMOUNT REPORTED
CORRECT AMOUNT
NUMBER
( + OR - )
Firm Name: ___________________________________________
FOR INTERNAL USE ONLY
Signature:
___________________________________________
(State whether individual, owner, partner – title, if officer of Corporation)
_____________________________________________
(Account Adjusted By)
Date:
___________________________________________
DLLR Home Page:
E-mail: uiacctsrec@dllr.state.md.us
Martin O’Malley, Governor
Anthony G. Brown, Lt. Governor
Leonard J. Howie, III, Secretary
DLLR/DUI 21 Web (Revised 1-13)

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