Form Ua 1019 - Amended Wage Detail Report - 1998
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1UA 1019
State of Michigan
(Rev. 5-98)
DEPARTMENT OF CONSUMER AND INDUSTRY SERVICES
UNEMPLOYMENT AGENCY
AMENDED WAGE DETAIL REPORT
1 . EMPLOYER NAME & ADDRESS
2 . UA ACCOUNT NO.
3 . FEDERAL EMPLOYER
4 . QUARTER
IDENTIFICATION NO.
ENDING DATE
5 . TOTAL GROSS W AGES REPORTED
( ACTUA L )
$
$
ON THE ORIGINAL FORM UA 1017
TOTAL GROSS W AGES
FOR THIS QUARTER
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS SECTION
6 . REASON FOR THE AMENDMENT:
PART A
PART B
E n t e r t h e c o m p l e t e i n fo rm a t i o n fo r e a c h e m p l oy e e a s i t s h o u l d a p p e a r i n o u r r e c o r d s.
(We w i l l a d j u s t o u r r e c o r d s a s n e e d e d . )
7 . SOCIAL SECURITY
8 . STATUS
9 . SOCIAL SECURITY
1 0 . EMPLOYEE’S NAME
1 1 . GROSS W AGES
NUMBER ON FORM
NUMBER
P A I D THIS
UA 1017
QUARTER
LAST
LAST
FIRST
FIRST
DOLLARS
DOLLARS
CENTS
CENTS
LAST
LAST
LAST
FIRST
FIRST
FIRST
DOLLARS
DOLLARS
DOLLARS
CENTS
CENTS
CENTS
1 2 . C e rt i f i c a t i o n : I c e rt i f y t h a t I h av e ex a m i n e d t h i s r e p o rt , a n d t o t h e b e s t
1 3 . TO
TO
TO
TO
TOT T T T T A L –
A L –
A L –
A L – THIS P
A L –
THIS P
THIS P
THIS P
THIS PA A A A A GE ONL
GE ONL
GE ONL
GE ONL
GE ONLY Y Y Y Y
o f my k n ow l e d g e a n d b e l i e f, i t i s c o r r e c t a n d c o m p l e t e.
S i g n a t u r e
D a t e
1 4 . GRAND
GRAND
GRAND
GRAND
GRAND T T T T T O O O O O T T T T T AL
AL
AL
AL
AL
( O N THE LAST PAGE ONLY )
(
)
T i t l e
Telephone
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e _ _ _ _ o f _ _ _ _ _
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