Form Uia 1019 - Amended Wage Detail Report - 2011

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UIA 1019
State of Michigan
Authorized by
(Rev. 5-11)
Department of Licensing and Regulatory Affairs
MCL 421.1, et seq.
UNEMPLOYMENT INSURANCE AGENCY
WAGE RECORD UNIT
3024 W. Grand Blvd., Suite 12-450, Detroit, MI 48202
Reset Form
AMENDED WAGE DETAIL REPORT
1. EMPLOYER NAME & ADDRESS
2. UIA ACCOUNT NO.
3. 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
6. REASON FOR THE AMENDMENT:
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS SECTION
PART A
PART B
List only the employee(s) for whom you are reporting corrections. If you are reporting a cor-
rected SSN, file one form for all quarters and do not report wage amounts.
7.
SOCIAL SECURITY
8. FAMILY
9. CORRECT
10. EMPLOYEE’S NAME
11. GROSS WAGES
NUMBER ON FORM
OWNED?
SOCIAL SECURITY
PAID THIS
UIA 1017
Enter “F”
NUMBER
QUARTER
LAST
FIRST
DOLLARS
CENTS
12. Certification: I certify that I have examined this report, and to the best of my knowledge and belief, it is correct and complete.
Signature of owner/officer Date
Name of contact person
Telephone
Page ____ of _____
LARA is an equal opportunity employer/program.

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