Form 3hadjc - Amended Wage List Continuation Sheet

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Utah Department of Workforce Services
DWS-UI
Form 3HADJC
Unemployment Insurance
Rev. 6/09
140 East 300 South
P.O. Box 45288
Salt Lake City, Utah 84145-0288
TEL (801) 526-9235 option 2 • Toll Free 1-800-222-2857 option 2
FAX (801) 526-9236
AMENDED WAGE LIST CONTINUATION SHEET
Page ______ of ______
EMPLOYER NAME AND ADDRESS
REGISTRATION NO. __________
_________________________________
FOR QTR ENDING _________________
_________________________________
QTR ________ YEAR ________
_________________________________
PAGE _____ OF _____
WAGES
CORRECT
SOCIAL SEC. #
EMPLOYEE NAME
REPORTED
WAGES
DIFFERENCE
ON WAGE LIST
TOTALS

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