Form Uc-522-Ff - Adjustment Report Form - Arizona Department Of Economic Security
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1UC-522-FF (5-12) – Page 2
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
ADJ
Scan both sides if box is checked.
Unemployment Tax - 911B
(Checkbox above is for DES use only.)
ACCOUNT NUMBER
P.O. Box 6028, Phoenix, AZ 85005-6028
Adjustment will be rejected unless the
Phone: 602-771-6601 Fax: 602-532-5562
reason for it is provided at the bottom of
CALENDAR QUARTER ENDING
this form. Use reverse side if more space
ADJUSTMENT REPORT
is needed.
EMPLOYER’S NAME
ADDRESS (No., Street, City, State, ZIP)
CORRECTION TO REPORT OF WAGES PAID TO INDIVIDUAL EMPLOYEES
THIS BOX FOR AGENCY USE ONLY
Employee’s Social
Amount of Wages
Correct Amount
KEY
KEY
Employee’s Name
Security Number
Previously Reported
of Wages
Net Increase
Net Decrease
First
0 0 0 0 0 0 0 0 0
Last
Dollars
Cents
Dollars
Cents
Dollars
Cents
Dollars
Cents
Initial
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CORRECTION TO TAXABLE WAGES & AMOUNTS DUE
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TOTALS:
PREPARED BY
DATE
As Previously Reported
As Corrected
Net Increase
Net Decrease
Total Wages
$
$
$
$
VERIFIED BY
DATE
Excess Wages
$
$
$
$
Taxable Wages
$
$
$
$
UI TAX
Adjustment at
% (tax rate in effect for quarter indicated above)
$
$
UI INTEREST
YOUR SIGNATURE
Add 1% for each full and/or partial month from delinquent date
$
JOB TRAINING TAX
Adjustment at 0.10% of Taxable Wages
$
$
SPECIAL ASSESSMENT (APPLIES TO CALENDAR QUARTERS IN 2011 AND 2012 ONLY)
YOUR TITLE
Adjustment at 0.40% (2011) or 0.50% (2012) of Taxable Wages
$
$
NET ADJUSTMENT
YOUR PHONE NUMBER
DATE
$
Underpayment
NET ADJUSTMENT
Overpayment
$
REASON FOR ADJUSTMENT (Required):
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