Tax And Wage Report Adjustment Form - New Hampshire

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32 SOUTH MAIN STREET
RICHARD S. BROTHERS, Commissioner
CONCORD NEW HAMPSHIRE 03301-4857
DARRELL L. GATES, Deputy Commissioner
TAX AND WAGE REPORT ADJUSTMENT FORM
(A separate form must be submitted for each quarter - This form can be reproduced)
EMPLOYER NAME:
ACCOUNT #
Quarter Ended__________________
Request is hereby made for an adjustment to my account for the following reasons:_____________________________________
2nd Month
3rd Month
CORRECTIONS - PART 1 (Tax Report)
1st Month
Line 7
CORRECTIONS - PART 1 (Tax Report)
Tax Report Line
Item
Amount Previously
Correct Amount
Difference (+ or -)
Reported
Line 8
Total Wages
Line 9
Excess Wages
Line 10
Taxable Wages
Line 11
UI Rate
Line 12
AC Rate **
Line 13
Total Tax Due
* Interest Due
* Interest should be calculated at 1% per month on total tax due
**For adjustments prior to 2002 do not use AC Rate
Balance or Credit Due
CORRECTIONS - PART 2 (Wage Report)
Social Security #
Employee Name
Amount Previously
Correct Amount
Reported
SIGNATURE_________________________
TITLE__________________
DATE_________________
PHONE______________
NHES is a proud member of America's Workforce Network and NH WORKS. NHES is an Equal Opportunity Employer and
complies with the Americans with Disabilities Act. Auxiliary aids and services are available upon request of individuals with disabilities.
Telephone: (603)224-3311
Fax: (603)229-4323
Web:
TDD ACCESS: RELAY NH 1(800)735-2964

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