Form Dllr/oui 21 - Request For Wage Adjustment
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1MARTIN O’MALLEY, Governor
DLLR
ANTHONY G. BROWN, Lt. Governor
ALEXANDER M. SANCHEZ, Secretary
STATE OF MARYLAND
DLLR Home Page *
E-mail * uiacctsrec@dllr.state.md.us
DEPARTMENT OF LABOR LICENSING AND REGULATION
Office of Unemployment Insurance
Accounts Receivable Unit – Room 415
1100 North Eutaw Street
Baltimore, Maryland 21201
Federal Number ____-_________________
1-800-492-5524 Ext. 2410
Local 410-767-2410
Fax
410-767-2680
Request for Wage Adjustment
(A Separate Form Must Be Submitted For Each Quarter)
Gentlemen:
Request is hereby made for an adjustment to my account for the following reason(s):
AMOUNT OF REMITTANCE
$
FOR QUARTER ENDING:
(If Applicable)
00__________________
EMPLOYER ACCOUNT NUMBER:
ITEM
AMOUNT REPORTED
CORRECTED AMOUNT
DIFFERENCE (+ OR -)
Total wages
Excess wages
Taxable wages
X Tax Rate
.0____
.0____
.0____
Contributions (Tax)
*Interest should be calculated at .5% per month from the quarterly due date.
$
INTEREST DUE
(Make your check payable to Maryland Unemployment Insurance Fund)
Total $
WAGE DETAIL
If more space is needed, please send on additional blank sheets.
SOCIAL SECURITY
EMPLOYEE NAME
AMOUNT REPORTED
CORRECT AMOUNT
DIFFERENCE ( + or - )
NUMBER
FOR INTERNAL USE ONLY
Firm Name:
(Account Adjusted By:)
Signature:
(State whether individual, owner, partner – title, if officer of Corporation)
Date:
DLLR/OUI 21 (Web Revised 04-10)
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