Correction Of Wage Item(S) Form

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EMPLOYER NUMBER
CORRECTION OF WAGE ITEM(S)
EMPLOYER’S NAME
Alaska Department of Labor and Workforce Development
Employment Security Division
P.O. Box 25509, Juneau, AK 99802-5509
SOCIAL
EMPLOYEE NAME
_________ QTR./YR ________
w
_________ QTR./YR ________
w
________ QTR./YR ________
w
_______ QTR./YR _______
w
SECURITY
REPORTED
CORRECT
REPORTED
CORRECT
REPORTED
CORRECT
REPORTED
CORRECT
NUMBER
TOTALS:
EXPLANATION:
I CERTIFY that to the best of my knowledge, the foregoing information is true and correct.
Adj Keyed: __________
Batch #: __________
Date _________By____________________________ Title____________________________________________
Checked By: __________
SUMMARY OF ADJUSTMENTS – AGENCY USE ONLY
TOTAL WAGES
TAXABLE WAGES
BATCH / ITEM
YR/QTR
RATE
CORRECT
REPORTED
DIFFERENCE
REPORTED
CORRECT
DIFFERENCE

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