Form Sfn 41270 - Statement To Correct Employer'S Contribution And Wage Report

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STATEMENT TO CORRECT EMPLOYER'S CONTRIBUTION AND WAGE REPORT
Job Service North Dakota
JOB SERVICE NORTH DAKOTA
TAX SECTION
PO Box 5507
SFN 41270 (R. 3-99)
Bismarck ND 58506-5507
Check our Web Page @
701-328-2814 800-472-2952
TTY: Relay ND 800-366-6888
Employer Name
Unemployment Insurance Account Number
Address
Year
Page
FIRST QUARTER
SECOND QUARTER
THIRD QUARTER
FOURTH QUARTER
SSN
NAME
Reported
Corrected
Reported
Corrected
Reported
Corrected
Reported
Corrected
FIRST QUARTER
SECOND QUARTER
THIRD QUARTER
FOURTH QUARTER
Quarterly Totals
Reported
Corrected
Reported
Corrected
Reported
Corrected
Reported
Corrected
Total Wages
Excess Wages
Taxable Wages
Net. Diff. Taxable Wages
Adj. (Rate x Net Diff.)*
Explanation of changes:
Signature
Title
Date
*Interest will be charged at 1.5 percent per month on the unpaid balance.
Job Service North Dakota is an equal opportunity employer/program provider. Auxiliary aids and services are available upon request.

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