Tax And Wage Report Adjustment Form - Employment Security

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Employer Account #, Name & Address
_________________________________
_________________________________
_________________________________
TAX AND WAGE REPORT ADJUSTMENT FORM
(A separate form must be submitted for Each Quarter- This form can be reproduced)
Request is hereby made for an adjustment to my account for the following reasons:__________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CORRECTIONS - PART 1 (Tax Report)
Quarter ended___________________
Tax Report Line
Item
Amount Previously
Correct Amount
Difference(+ or -)
Reported
Line 8
Total Wages
Line 9
Excess Wages
Line10
Taxable Wages
Line 11
Rate
* Interest should be calculated at 1% per month
* Interest Due
Balance or Credit due
CORRECTIONS - PART 2(WAGE REPORT)
Social Security #
Employee Name
Amount previously Reported
Correct Amount
DATE __________________________
SIGNATURE________________________
TITLE ________________________
TELEPHONE # ________________________

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