Enter the state unemployment insurance tax account number.
Enter the federal identification number.
Enter the calendar year and quarter being corrected.
Enter the employer's experience rate for the year being corrected.
Enter the employer's name, business name, and mailing address.
Enter the total wages, excess wages and taxable wages reported on the original
report.
Enter the contributions paid for the year quarter being corrected. Do not round this amount.
Enter the amended total wages, excess wages and taxable
wages for the year quarter being corrected.
Enter the amended contributions due.
(Multiply the amended taxable wage amount times the experience rate for the year /quarter being corrected).
Do not round this amount.
Enter the amount of the overpayment. (Amended Contributions due minus
Contributions Paid). Do not round this amount.
Enter the amount of the underpayment. If the contributions
were underpaid, the remittance amount should include the appropriate interest
and penalty.
Enter the total remittance amount. In the case of tax
underpayments, checks are to be made payable to the Office of Regulatory
Services. Noted below is an example of interest and penalty calculations.
Assume the underpayment is 15 days past the due date for
the 1st quarter of 2000 (due 4/30/00).
The underpayment equals $352.50. Interest is calculated
at 1% per month or portion thereof. In this case, interest equals $1.74.
Penalty accrues at 5% per month (not to exceed 25%) on the 1st day. The
penalty calculation is 5% of the underpayment plus the interest due. In
this case, penalty equals $17.71. The total a mount of the remittance
would equal $371.95.
Enter a brief explanation for filing the amended report.
NOTE: If the total wages have increased or decreased the
lower section of the form must be completed for each individual employee
involved in the correction.
Enter the employee's social security number.
Enter the employee's first and last name
Enter the original wages reported for the employee.
Enter the amended wages the employee.
NOTE: If additional lines are needed to list more employees
attach the Amended Continuation Wage Listing sheet provided on the web
site. (Amended Continuation Wage Report)
Your signature is required on this document. Unsigned
amendment forms will not be processed and returned to the sender.
