DO NOT USE THIS FORM TO FILE A QUARTERLY REPORT
AUXILIARY AIDS AND SERVICES ARE AVAILABLE UPON
THIS FORM IS ONLY TO BE USED TO AMEND A REPORT THAT HAS ALREADY BEEN FILED.
REQUEST TO INDIVIDUALS WITH DISABILITIES
OKLAHOMA EMPLOYMENT SECURITY COMMISSION
EMPLOYER’S QUARTERLY ADJUSTMENT REPORT
RESET
PO Box 52003
Oklahoma City, OK 73152-2003
0.00
6. Correct total wages paid this quarter
$ _________________________
2. Oklahoma Account Number
1. Federal Identification Number
6-a. Total wages previously reported
$ _________________________
3. Name/Address
6-b. Total wages under reported
$ _________________________
6-c. Total wages over reported
$ _________________________
(Enter as Negative)
7. Correct wages in excess of taxable limitation $ _________________________
0.00
8. Correct taxable wages paid this quarter
$ _________________________
8-a. Taxable wages previously reported
$ _________________________
8-b. Taxable wages under reported
$ _________________________
4. I certify that the information contained in this report is true and correct.
$ _________________________
8-c. Taxable wages over reported
(Enter as Negative)
Signed _________________________________________________
0.0%
9. Contribution Rate (Enter rate as a decimal)
_________________________
Title ____________________________ Date ___________________
0.00
10. Contribution Due (Item 8-b x Item 9)
$ _________________________
5. Quarter ______________________
11. Interest due (1% per month from due date)
$ _________________________
0.00
12. Total amount due with this report
$ _________________________
List in the schedule below ONLY those
PLEASE NOTICE:
employees whose wages are being
0.00
13. Credit due (Item 8-c x Item 9)
$ _________________________
corrected.
14. Oklahoma Account Number ____________________________
15. Quarter ______________________
Employee’s Name
Total Wages
Taxable Wages
*Correct Total
*Correct Taxable
16. Employee’s Social
(Type or Print)
Previously Reported
Previously Reported
Wages Paid
Wages Paid
Security Number
0.00
0.00
0.00
0.00
ENTER THE TOTALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOR COMMISSION USE ONLY-DO NOT WRITE IN THE SPACES BELOW
Date Rec’d
Batch #
003B
EQUAL OPPORTUNITY EMPLOYER/PROGRAM
OES-3B (Rev. 1-17)