Form K-Cns 111 - Adjustment To Quarterly Wage Report(2008)
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1Kansas Department of Labor
401 SW Topeka Blvd • Topeka KS 66603-3182
Adjustment to Quarterly Wage Report
Telephone – 785-296-5027 • Fax – 785-291-3425
Internet Address –
1. EMPLOYER NAME AND ADDRESS
2. QUARTER/YEAR
3. REASON FOR ADJUSTMENT
_________/________
6. PAGE ______ OF
4. _______________________
5. __________%
7.
________PAGES
ACCOUNT NUMBER
RATE
SIGNATURE
DATE
10.
TOTAL WAGES
11.
EXCESS WAGES
8. SOCIAL SECURITY #
9. NAME (LAST, FIRST, M.I.)
10a
REPORTED
10b
CORRECT
11a
REPORTED
11b
CORRECT
AGENCY USE
12. TOTALS
12a
12b
12c
12d
13. TOTAL WAGE
13a
+
DEPOSIT
DIFFERENCE
–
14. EXCESS WAGE
14a
+
CODE 13
DIFFERENCE
–
15. NET DIFFERENCE
15a
+
AGENCY USE
CODE 14
TAXABLE WAGES
–
16. TAX DUE
16a
UP
CONTR.
OR OVERPAID
OP
DATE RECEIVED
K-CNS 111 (Rev. 11-2008)
(INSTRUCTIONS ON REVERSE)
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