Form 3adj - Amended Employer'S Contribution Report - Utah Department Of Workforce Services
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1Form 3ADJ
Utah Department of Workforce Services, Unemployment Insurance
Rev 0317
Unemployment Insurance
140 E. 300 S., PO Box 45288, Salt Lake City UT 84145-0288
1-801-526-9235
1-800-222-2857
The preferred method of filing this report is on-line at our website:
Amended Employer's Contribution Report
EMPLOYER NAME & ADDRESS:
Registration #:
Quarter:
Year:
The preferred method of filing this
report is online at our website:
/ui
As Reported on
E M P L O Y E R ' S
CONTRIBUTION REPORT
CORRECT AMOUNT
DIFFERENCE
(Form 33H)
Total Wages:
Excess Wages:
Subject Wages:
Contribution Due:
PAYMENT SUMMARY
INSTRUCTIONS
1. Use a separate form for each quarter
Previous Payment This Quarter:
$
amended.
2. Total payroll reported on your Form 3 should
Additional Contribution Due:
$
show on this form.
3. Corrections must be made in the quarter the
Interest Due:
$
wages were actually paid; i.e. 1st quarter
amendments cannot be made in the 2nd quarter.
Additional Contribution Paid:
$
4. If individual wages are adjusted, attach a Form
3HADJ, Amended Wage List.
Refund Due:
$
Explanation for Amendment:
Printed Name:______________________________________ Telephone: (_______)______________________
Signature: __________________________________ Title:________________________ Date:__________________
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