Form 07-1496-01 - Employer Option Form - Alaska Department Of Labor Page 4
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4Option Form for Labor Disputes and/or Payroll Changes
For Rating Purposes Only
LABOR DISPUTES
(1) Quarter ending dates
(2) Total quarterly wages as reported
(3) Total quarterly wages that would
(4) Adjusted total quarterly wages
on your contribution report for
have been reported if there was no
SHADED AREA FOR DEPARTMENTAL USE ONLY
quarters listed in Column (1)
labor dispute
Explanation: __________________________________________________________________________________________________________________________________
PAYROLL CHANGE
(1) Quarter ending dates - Each
(2) Total quarterly wages as reported
(3) Total quarterly wages that would
(4) Adjusted total quarterly wages
quarter listed with a payroll change
on your contribution report for
have been reported if a payroll change
SHADED AREA FOR DEPARTMENTAL USE ONLY
must have an offsetting amount as a
quarters listed in Column (1)
had not occurred.
correction to another quarter.
A change in wages in one quarter
must have an offsetting amount as a
correction to another quarter.
(A) Quarter with change:
(B) Offsetting quarter:
(A) Quarter with change:
(B) Offsetting quarter:
(A) Quarter with change:
(B) Offsetting quarter:
Explanation: __________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Account No: ___________________________ Account Name: ______________________________________________________________________________________
Date: __________________ Contact Person: _______________________________________________________ Telephone Number: _________________________
Form
07-1496-01 (Rev 12/98)
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