Form 11a - Combined Tax Report/wage Report
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1UI11A Revised 4/06/06
Nebraska Workforce Development
Department of Labor, U. I.
WC
P O Box 94600
Lincoln, NE 68509-4600
Ph: (402) 471-9982
Fax (402) 471-9994
Employer Name
Employer Account Number
ADJUSTMENT FORM 11A
YR
QTR
NEBRASKA COMBINED TAX REPORT/WAGE REPORT
AS REPORTED
SHOULD BE
Dollars
Cents
Dollars
Cents
$
$
2.
Gross wages paid for covered employment during the quarter
$
$
3.
Wages in excess (2005 & prior = $7,000; 2006 = $8,000; 2007 = $9,000)
$
$
4.
Total Taxable Wages (subtract line 3 from line 2)
$
$
5.
Your CONTRIBUTION rate
%
Multiply line 4 by
$
$
6.
Your SUIT rate
%
Multiply line 4 by
%
7.
Your COMBINED TAX rate
$
8.
$
Enter COMBINED TAX PAYMENTS DUE for this quarter. Multiply line 4 by line 7
$
$
9.
Adjustment
IF YOU HAVE OVERPAID COMBINED TAX, A CREDIT WILL BE SET UP IN YOUR ACCOUNT. IF YOU HAVE UNDERPAID
COMBINED TAX, ENCLOSE PAYMENT FOR THE ADDITIONAL COMBINED TAX DUE PLUS INTEREST
AT 1.5% PER MONTH FROM ONE MONTH AFTER THE END OF THE QUARTER UNTIL PAID.
Contact
Phone
Date
ADJUSTMENT FORM 11A
IF GROSS WAGES WERE CHANGED ABOVE, SHOW
Employer Account Number
ONLY THE INDIVIDUALS THAT REQUIRE CORRECTIONS.
SOCIAL SECURITY NUMBERS MUST BE INCLUDED
YR
QTR
GROSS WAGES PAID EACH COVERED EMPLOYEE
SOCIAL SECURITY NUMBER
IN THIS 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
Contact
Phone
Date
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