Form Uco-341a - Wage Information In Support Of A Claim For Refund

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1NSTRUCTIONS:This form must be used in support of a claim for refund. Prepare a separate form for each calendar year in which you feel that you paid wages
“CO-341A (R 5-W)
OHIO BUREAU OF EMPLOYMENT SERVICES
145 SOUTH FRONT STREET. P.O. BOX 923
COLUMBUS, OHIO 43216-0923
WAGE INFORMATION in SUPPORT of a CLAIM for REFUND
Employer
Number
Business Name of Employer
for services not covered by the unemployment compensation law, or in which you overreported wages.
In BLOCK “A,” list names, social security account numbers and gross wages for all employees.
Total gross wages for each quarter should agree
with gross wages previously submitted on quarterly reports.
In BLOCK “B,” list all non-taxable wages which have been reported. BLOCK “A,” quarterly totals minus BLOCK “B,” quarterly totals should
equal correct taxable wages.
If there are any discrepancies between originally reported gross wages and those shown on this form please explain on form UCO-341.
BLOCK B
BLOCK A
SOCIAL SECURITY
Year 19-
WAGES OVERREPORTED
Year 19-
GROSS WAGES PAID
WORKER’S NAME
ACCOUNT NUMBER
Third
Fourth
First
Second
Third
Fourth
First
Second
Quarter
Quarter
Quarter
Quarter
Quarter
Quarter
Quarter
Quarter
Quarterly
EMPLOYER
COPY 1 - RETURN TO THE BUREAU
Totals
COPY 2 - RETAIN FOR YOUR FILES

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