Form 3hadj - Amended Wage List printable pdf download

Form 3hadj - Amended Wage List

DWS-UI

Utah Department of Workforce Services

Form 3HADJ

Unemployment Insurance

Rev. 4/98

140 East 300 South

P.O. Box 45288

Salt Lake City, Utah 84145-0288

TEL (801) 526-9400

FAX (801) 526-9236

AMENDED WAGE LIST

EMPLOYER NAME AND ADDRESS

REGISTRATION NO. __________

_________________________________

FOR QTR ENDING __________________

_________________________________

QTR ________ YEAR ________

_________________________________

PAGE 1 OF _____

WAGES

CORRECT

SOCIAL SEC. #

EMPLOYEE NAME

REPORTED

WAGES

DIFFERENCE

ON WAGE LIST

TOTALS

FOR OFFICE USE ONLY

Adjustments:

Deletions:

[ ] Wage Data Correction Only

[ ] Family Member

[ ] Reported to Wrong SS#

[ ] Member LLC

[ ] Wages Overstated

[ ] Reported to Utah in error -

[ ] Wages Understated

Reportable to ________________

[ ] Other _______________________________________

JE # __________________________________________ Initial _______________ Date __________________

Form 3hadj - Amended Wage List