Form De 678 - Tax And Wage Adjustment Form - 2004 Page 2
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2TAX AND WAGE ADJUSTMENT FORM
EMPLOYER ACCOUNT NO.
NAME or DBA
SECTION V: QUARTERLY WAGE AND WITHHOLDING ADJUSTMENTS
Enter amounts that should have been reported, if unchanged leave field blank. Correcting the Social Security Number or
Name requires two entries. See Instruction Sheet (DE 678-I), Section V, for further information and instructions.
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
DE 678 Rev. 2 (4-04) (INTERNET)
Page 2 of 2
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