Form Uia 1019 - Amended Wage Detail Report - Michigan Department Of Labor & Economic Growth
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1UIA 1019
State of Michigan
(Rev.12-04)
DEPARTMENT OF LABOR & ECONOMIC GROWTH
UNEMPLOYMENT INSURANCE AGENCY
WAGE RECORD UNIT
3024 W. GRAND BLVD., SUITE 12-450, DETROIT, MICHIGAN 48202
AMENDED WAGE DETAIL REPORT
1.
2.
3.
EMPLOYER NAME & ADDRESS
EMPLOYER
ACCOUNT NO.
FEDERAL EMPLOYER
4.
QUARTER
IDENTIFICATION NO.
ENDING DATE
5.
TOTAL GROSS WAGES REPORTED
(ACTUAL)
ON THE ORIGINAL FORM UIA 1017 $
TOTAL GROSS WAGES
$
FOR THIS QUARTER
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS SECTION
6.
REASON FOR THE AMENDMENT:
PART A
PART B
Enter only the corrections as they should appear in our records.
(We will adjust our records as needed.)
7.
SOCIAL SECURITY
8. STATUS
9. SOCIAL SECURITY
10.
EMPLOYEE’S NAME
11.
GROSS WAGES
NUMBER ON FORM
NUMBER
PAID THIS
UIA 1017
QUARTER
LAST
FIRST
DOLLARS
CENTS
12. Certification: I certify that I have examined this report,
13.
TOTAL – THIS PAGE ONLY
and to the best of my knowledge and belief, it is correct
and complete.
Signature
Date
14.
GRAND TOTAL
(ON THE LAST PAGE ONLY)
(
)
Title
Telephone
Page ____ of _____
DLEG
E
O
E
A
D
A
.
IS AN
QUAL
PPORTUNITY
MPLOYER AND COMPLIES WITH THE
MERICANS WITH
ISABILITIES
CT
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