Form Uc-522 - Adjustment Report
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UC-522 (12-00)
Film both sides
Unemployment Tax, 911B
P.O. Box 6028 Phoenix, AZ 85005-6028
ACCOUNT NO.
Phone: (602) 248-9354 • Fax: (602) 650-1451
ADJUSTMENT REPORT
CALENDAR QUARTER ENDING
(Adjustment will be rejected unless explanation is completed on reverse.)
ADDRESS (No., Street, Suite No., City, State, ZIP)
EMPLOYER'S NAME
CORRECTION TO REPORT OF WAGES PAID EACH INDIVIDUAL EMPLOYEE
FOR AGENCY USE ONLY
KEY
KEY
Employee's Soc. Sec.
Amount of Wages
Correct Amount
Employee's Name
Account No.
Reported
of Wages
Net Increase
Net Decrease
0 0 0 0 0 0 0 0 0
First
Dollars
Cents
Dollars
Cents
Dollars
Cent
Dollars
Cents
Last
s
Initial
CORRECTION TO COMPUTATION OF
TOTALS
TAXABLE WAGES AND AMOUNTS DUE:
As Reported
As Corrected
Net Increase
Net Decrease
SIGNATURE
Total Wages
$
$
$
$
TITLE
Excess Wages
$
$
$
$
PHONE NO.
DATE
Taxable Wages
$
$
$
$
UI TAX
$
$
Adjustment at rate in effect for quarter indicated above
%
DO NOT WRITE BELOW THIS LINE
UI INTEREST
$
Add 1% for each month from delinquent date
JOB TRAINING TAX
$
$
PREPARED BY
DATE
Adjustment at 0.10% of Taxable Wages
NET ADJUSTMENT
$
Underpayment
VERIFIED BY
DATE
NET ADJUSTMENT
$
Overpayment
Equal Opportunity Employer/Program ♦ This document available in alternative formats by contacting the UI Tax Office.
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