Form 3adj - Unemployment Insurance printable pdf download

Form 3adj - Unemployment Insurance

Form 3ADJ

Utah Department of Workforce Services, Unemployment Insurance

Rev 07/2010

Unemployment Insurance

140 E. 300 S., PO Box 45288, Salt Lake City UT 84145-0288

1-801-526-9235 option 4

1-800-222-2857 option 4

The preferred method of filing this report is on-line at our website:

Registration #:

EMPLOYER NAME & ADDRESS:

Quarter:

Year:

As Reported on

E M P L O Y E R ' S

CONTRIBUTION REPORT

CORRECT AMOUNT

DIFFERENCE

(Form 3)

Total Wages:

Excess Wages:

Subject Wages:

Contribution Due:

PAYMENT SUMMARY

INSTRUCTIONS

1. Use a separate form for each quarter

Previous Payment This Quarter:

amended.

2. Total payroll reported on your Form 3 should

Additional Contribution Due:

show on this form.

3. Corrections must be made in the quarter the

Interest Due:

wages were actually paid; i.e. 1st quarter

amendments cannot be made in the 2nd quarter.

Additional Contribution Paid:

Refund Due:

Explanation for Amendment:

Printed Name:______________________________________ Telephone: (_______)______________________

Signature: __________________________________ Title:________________________ Date:__________________

Form 3adj - Unemployment Insurance