Request To Amend Unemployment Compensation Quarterly Tax Return Form (Page 2 of 2) in pdf

Request To Amend Unemployment Compensation Quarterly Tax Return Form Page 2

First

Middle

5. Employee's Last Name

6. Total Wages Paid this Quarter

7. Weeks

Initial

Enter the Social Security Number of the employee as originally filed.

If amending Social Security Number, enter the correct number.

Enter only the item to be amended (see items 5 - 7). If amending multiple items, you must complete a separate record for each item being amended.

Amendment

Comments:

Reason #

Enter the Social Security Number of the employee as originally filed.

If amending Social Security Number, enter the correct number.

Enter only the item to be amended (see items 5 - 7). If amending multiple items, you must complete a separate record for each item being amended.

Amendment

Comments:

Reason #

Enter the Social Security Number of the employee as originally filed.

If amending Social Security Number, enter the correct number.

Enter only the item to be amended (see items 5 - 7). If amending multiple items, you must complete a separate record for each item being amended.

Amendment

Comments:

Reason #

Enter the Social Security Number of the employee as originally filed.

If amending Social Security Number, enter the correct number.

Enter only the item to be amended (see items 5 - 7). If amending multiple items, you must complete a separate record for each item being amended.

Amendment

Comments:

Reason #

9. Certification: I certify that the information contained in this report is true and correct.

Signature:

Date:

Title:

Page 3 of 3

JFS 20129 (9/2010)

Request To Amend Unemployment Compensation Quarterly Tax Return Form Page 2