ADMINISTRATIVE OFFICE                    
                                                                  45 SOUTH )58,7  TREETS    
                                                                CONCORD , NH    03301-4857 
                                                                                                                      
GEORGE N. C  OPADIS  C, OMMISSIONER 

                           TAX AND WAGE REPORT ADJUSTMENT FORM
                  (A separate form must be submitted for each quarter - This form can be reproduced)

 EMPLOYER NAME:                                                                                         ACCOUNT #

                                                                                            Quarter Ended _________

Request is hereby made for an adjustment to my account for the following reasons: ______________________________

                                                                  st                  nd                          rd
CORRECTIONS - PART 1 (TAX REPORT)                                 1  Month            2  Month                    3  Month
                           Line 7
CORRECTIONS - PART 1 (TAX REPORT)
Tax Report Line                Item                 Amount Previously                 Correct Amount              Difference 
                                                                  Reported                                        (+ or -)
Line 8                  Total Wages
Line 9                  Excess Wages
Line 10                 Taxable Wages
Line 11                 UI Rate
Line 12                 AC Rate
Line 13                 Total Tax Due
*Interest should be calculated at 1% per month on total tax due                       * Interest Due
                                                                                      Balance or Credit 
                                                                                                        Due
CORRECTIONS - PART 2 (Wage Report)
Social Security #                      Employee Name                                  Amount Previously  Correct Amount
                                                                                      Reported

SIGNATURE                                           TITLE                             DATE                  PHONE
NHES is a proud member of America’s Workforce Network and NH Works. NHES is an Equal Opportunity Employer and complies 
 with the Americans with Disabilities Act. Auxiliary Aids and Services are available on request of individuals with disabilities 
                                                                         
Telephone (603) 224-3311   FaxFax(603)225-4323(603) 228-4145    TDD/TTY Access: Relay 1-800-735-2964    Web site: www.nhes.nh.gov 

                                                                                                                          R - 4/13