Adjustment Form 11a - Amendment To Combined Tax Report
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1UI11A Revised 2011
STATE OF NEBRASKA
DEPARTMENT OF LABOR
WC
UNEMPLOYMENT INSURANCE TAX
P O BOX 94600
ADJUSTMENT FORM 11A
LINCOLN NE 68509-4600
Ph: 402.471.9898
Fax: 402.471.9994
Employer Name
Employer Account Number
AMENDMENT TO COMBINED TAX REPORT – (UI – 11T)
YR
QTR
If combined tax has been overpaid, a credit will be established on the account. If combined tax
has been underpaid, enclose a payment for the additional combined tax due (line 9), plus interest
calculated at 1.5% per month from quarterly due date.
AS REPORTED
SHOULD BE
Dollars
Cents
Dollars
Cents
$
$
2.
Gross wages paid for covered employment during the quarter
$
$
Wages in excess ( For 2007 and after = $9,000)
3.
$
$
Total Taxable Wages (subtract line 3 from line 2)
4.
%
Your COMBINED TAX Rate is
5.
$
Enter COMBINED TAX PAYMENTS DUE for this quarter. Multiply line 4 by line 5
6.
$
$
$
Adjustment
7.
Reason for Adjustment:
Print Preparer’s Name:
Phone
Date
ADJUSTMENT FORM 11A
AMENDMENT TO WAGE REPORT – (UI – 11W)
Employer Account Number
If gross wages were changed in the SHOULD BE column above, list only the individuals
that require corrections. Social security numbers must be included.
YR
QTR
GROSS WAGES PAID EACH COVERED EMPLOYEE IN THIS
SOCIAL SECURITY NUMBER
QUARTER
Employee’s Name
AS REPORTED
SHOULD BE
AS REPORTED
SHOULD BE
Last Name, 1st Initial, 2nd Initial
000
00
0000
000
00
0000
Dollars
Cents
Dollars
Cents
Reason for Adjustment:
Print Preparer’s Name:
Phone
Date
Revised 2011
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