Form Uct-7842 - Contribution Adjustment Report - 2011
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1CONTRIBUTION ADJUSTMENT REPORT
Unemployment Insurance
P.O. Box 7945
Wisconsin Department of Workforce Development
Madison, WI 53707-7945
READ INSTRUCTIONS ON REVERSE SIDE
(608) 261-6700
1. Account Number
2. Quarter
3. Year
4.
To adjust the number of employees, place the
correct number employed as of the 12th of each
month in the correct box.
1st Month
2nd Month
3rd Month
5. Employer Name and Address:
Office
(C) Difference
(A) Previously Reported for
(B) Correct Totals
Use
this Quarter
(over) under
Only
6.
Total Covered Wages
7.
Less Exclusions for
Wages in Excess of
8.
Defined (Taxable) Payroll
9.
Rate
10.
Contribution Underpaid
or (Overpaid). Multiply
Line 8 by Rate.
11.
If contributions line 10(C) are (OVERPAID) go to item 12.
If contributions on line 10(C) are UNDERPAID, compute interest and ENTER HERE.
(Compute interest at 1% per month for each completed or partial month since the original
report due date. Multiply that interest by underpaid contributions on line 10(C).
12.
TOTAL DUE - Add on line 10(C) and line 11(C) and ENTER HERE.
(OVERPAID)
13.
Signature
Date
Title
Phone Number
(
)
-
BELOW THIS LINE FOR OFFICE USE ONLY
262
EFFECTIVE DATE
MONTH
DAY
YEAR
EMPLOYER NAME
ACCOUNT NUMBER
CHECK AMOUNT
*UCT-7842-E*
000002170043
UCT-7842-E (R. 03/29/2011)
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