Form Uc-2ax - Corrected Pennsylvania Gross Wages Paid To Employees
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1_____ of _____
CORRECTED PENNSYLVANIA GROSS WAGES PAID TO EMPLOYEES
1.
EMPLOYER ACCOUNT NUMBER
3.
QUARTER/YEAR
(A separate form must be submitted for each quarter)
R or M
CHECK DIGIT
1, 2,
3 or 4
2. Employer Business Name and Address:
4. Reason For Correction (Check all that apply):
Incorrect Employee Social Security Number________________________________
Correct Employee Social Security Number____________________________________
Employee Name__________________________________________________________
Incorrect Employee Name________________________________________________
Correct Employee Name___________________________________________________
Employee Social Security Number ________________________________________
Exempt Wages. Reason:_________________________________________________
Employee Wage Adjustment (attach UC-2X, if necessary)
Reason:________________________________________________________________
Incorrect Credit Weeks
Other (Please explain):___________________________________________________
5. I certify that the information on this form is true and correct to the best of my knowledge and belief. No part of the amount of employer
contributions reported on taxable wages was deducted or is to be deducted from the employees’ wages.
_____________________________________________________________________________________________________________________________________________
SIGNATURE OF OWNER, OFFICER, PARTNER, RESPONSIBLE OFFICER OR AUTHORIZED AGENT
TITLE
DATE
PHONE NUMBER
PLANT NUMBER
GROSS WAGES
CREDIT
NAME OF EMPLOYEE
6.
EMPLOYEE’S SOCIAL SECURITY NO.
WEEKS
FIRST NAME
INITIAL
LAST NAME
DOLLARS
CENTS
UC-2AX REV 06-16 (Page 1)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES
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