Form K-Cns 111 - Adjustment To Quarterly Wage Report

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KANSAS DEPARTMENT OF LABOR
K-CNS 111 (Rev. 06-2010)
ADJUSTMENT TO QUARTERLY WAGE REPORT
PRINT CLEARLY in UPPER CASE - use BLACK INK
Q
Y
Y
Y
Y
1.
Business
3.
Rate
2.
Employer
4.
Quarter/Year
Name:
Serial Number
6. Employee
Total Wages This Quarter
Excess Wages This Quarter
5. Social Security Number
7. Total Reported
8. Total Correct
9. Excess Reported
10. Excess Correct
Last Name
FI
MI
Dollars
Cents
Dollars
Cents
Dollars
Cents
Dollars
Cents
11.
Number of
12.
Total for THIS page
continuation
sheets
13.
Total for ALL pages
attached
14.
Adjustment Reason:
15.
Total Wage Difference
16.
Excess Wage Difference
17.
Net Difference Taxable Wages
20.
I certify that the information I have provided on this report is complete, correct and true, to the best of my
knowledge and belief
18.
Tax Due
Signature
19.
Tax Overpaid
Date Signed
M
M
D
D
Y
Y
Y
Y
FILE ONLINE AT: OR RETURN TO: Kansas Department of Labor P.O. Box 400, Topeka, KS 66601-0400

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