Form K-Cns 111 - Adjustment To Employer'S Wage Report
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1Adjustment to Employer’s
DEPARTMENT OF HUMAN RESOURCES
Wage Report
401 S Topeka Blvd
Topeka KS 66603-3182
913-296-5024
1. EMPLOYER NAME AND ADDRESS
2. QUARTER/YEAR
3. REASON FOR ADJUSTMENT
________ / ___________
4. ____ ____ ____ ____ ____ ____
5. ____ . ____ ____ %
6. PAGE ________OF
7.
_________________________________________________________________________ ________________
ACCOUNT NUMBER
RATE
__________PAGES
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
___________
DIFFFERENCE
-
14. EXCESS WAGE
14a +
CODE 13
___________
DIFFERENCE
-
15. NET DIFFERENCE
15a +
AGENCY USE
CODE 14
___________
TAXABLE WAGES
-
16. CONTRIBUTIONS
16a
UP
CONTR.
DATE RECEIVED
___________
DUE OR OVERPAID
OP
K-CNS 111 (Rev. 5-92)
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