Form Lb-0459 - Claim For Adjustment Or Refund

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(Do not write in this space)
Claim No.______________
Date Rec'd ____/____/____
TENNESSEE DEPT OF LABOR AND WORKFORCE DEVELOPMENT
Examined ________________________________________
EMPLOYER ACCOUNTS OPERATIONS
EMPLOYER ACCOUNTING UNIT
Wage Records Corrected ____________________________
220 FRENCH LANDING DRIVE
NASHVILLE TN 37243
(615)741-1619
FAX (615)741-7214
Approved _________________________________________
CLAIM FOR ADJUSTMENT
Adj. Prepared by ________________ Date ____/____/____
OR REFUND
A claim for adjustment is hereby made in accordance with Section 50-7-404(F) of the Tennessee Employment Security Act
because of premiums erroneously paid to the Tennessee Department of Labor and Workforce Development.
Name of Employer _________________________
State Account Number _________________________
Street Address ____________________________
Federal I.D. Number ___________________________
City and State _____________________________
Quarter(s) and Year(s)__________________________
Date Premiums Paid ________________________
Amount claimed as refund _______________________
In the space below explain why the wages are being decreased.
List employees erroneously reported showing by quarter the amount of wages reported and the amount
that should have been reported. Attach additional sheets if necessary. If employee(s) should be reported
to another state, please provide proof of report and payment to that state.
Total
Correct
Diff.
Taxable
Correct
Diff.
Social Security
Name of Employee
Qtr.
Wages
Total
Wages
Taxable
Number
Reported
Wages
Reported
Wages
It is understood that any adjustment allowed will be made in connection with subsequent premium payments, without
interest, unless such an adjustment cannot be made, in which case a refund will be made, without interest. Under the
penalties of perjury I declare that the statements made in support of this claim are true, correct and complete, to the best of
my knowledge and belief.
Signature of Preparer _______________________________
If prepared by Agency Representative
Title ________________________ Date _____/_____/_____
Signature ______________________________________
Preparer's Phone Number ____________________________
Date _____/_____/_____
LB-0459 (R. 1/06)
RDA 2438

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