UI-3B 
R03/05               MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY 
                                                         
                                               Post Office Box 22781 
                                    Jackson, Mississippi 39225-2781 
                                    Telephone Number: (601)321-6063 
                                                         
                         EMPLOYER'S QUARTERLY ADJUSTMENT REPORT 
                                                         
If the Social Security number, name or wages of one or more workers were omitted from or erroneously 
reported in a wage report, each such error should be corrected on this form.  Complete a separate UI-3b for each 
quarter requiring a correction. 
 
ADJUSTMENT FOR THE QUARTER ENDING                        PAGE NO.     OF                               PAGES FOR THIS QUARTER 
                                                                                       
MDES ACCOUNT NUMBER        TAX RATE             QTR/YR                           EMPLOYER'S NAME
WAGE ADJUSTMENTS TO UI-3 
 SOCIAL SECURITY  2.                           3.    TOTAL WAGES PAID                          4. TOTAL WAGES PAID       DO NOT USE 
        NUMBER       EMPLOYEES NAME                        THIS QUARTER                        THIS QUARTER SHOULD       THIS COLUMN 
                                                                                               BE 
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                               $                                               $                          
                                                                                                                          
5. TOTALS                                      $                                               $               
6. DIFFERENCES                                  
(Column 3 Total - Column 4 Total )                                                             $                          
 
7. REASON FOR ADJUSTMENT           
       
SIGNATURE                                                                                      DATE         
                                                                                                 
                                                     COLUMN A                                     COLUMN B                DIFFERENCE OF 
         CONTRIBUTIONS ADJUSTMENT TO UI-2           AS REPORTED                                   SHOULD BE          COLUMN A & COLUMN B 
8.  TOTAL GROSS WAGES PAID THIS QUARTER                           .                                             .                           .    
9.  NON-TAXABLE WAGES PAID THIS QUARTER                           .                                             .                           .    
10. TAXABLE WAGES PAID THIS QUARTER                               .                                             .                           .    
11. UI CONTRIBUTIONS DUE                                          .                                             .                           .    
12. TRAINING CONTRIBUTIONS DUE                                    .                                             .                           .    
13. TOTAL CONTRIBUTIONS DUE (add item 11 & 12)                    .                                             .                           .    
14. INTEREST ON ITEM 13                                           .                                             .                           .    
15. DAMAGES ON ITEM 13                                            .                                             .                           .    
16.TOTAL PAYMENT DUE                                              .                                             .                           .    
 
REASON FOR ADJUSTMENT                                                                                                    
                               
MDES ACCOUNT NUMBER      TAX RATE   QTR/YR             EMPLOYER'S NAME AND ADDRESS 
I certify that the information contained in this report and any subsequent pages attached is true and correct and that no part of the tax was or is to be deducted from the worker's 
wages. 
                                                                                                                                   
Telephone Number  Signature of individual making return or responsible therefore       Title                              Date