Form Ncui 685 - Adjustment To Employer'S Quarterly Tax & Wage Report - 2017
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1
2North Carolina Department of Commerce
Division of Employment Security
Unemployment Insurance
Adjustment to Employer's Quarterly Tax & Wage Report
1. Employer's Name, Address & Telephone:
2. Account Number (s):
3. Quarter/Year:
4. Tax Rate:
%
Contact Person's Telephone Number:
(
) -
-
ext.
FOR AGENCY USE ONLY
Ck Amount
Date
Col.
Initial
$
YES
NO
As Reported
As Corrected
5. (A) Wages Paid This Quarter Subject To The Law:
$
$
(B) Less Wages Paid This Quarter In Excess of
$
$
$
Per Worker This Year:
(C) Wages Subject To Tax:
$
$
6. Tax Paid/Due This Quarter:
$
$
7. Additional Tax Due:
8. Interest Due:
9. Penalty - Late Payment Due:
10. Total Due: Check Attached
Refund:
11. (A) Social Security Number
(B) Employee’s Name
(C) As Reported
(D) As Corrected
-
-
$
$
-
-
$
$
-
-
$
$
-
-
$
$
-
-
$
$
-
-
$
$
-
-
$
$
-
-
$
$
Total:
Total:
12. Reason:
13. This information is true and accurate.
Signed:
Title:
Date:
NCUI 685 (Rev. 01/2017)
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