JOB SERVICE NORTH DAKOTA 
                          STATEMENT TO CORRECT EMPLOYER'S CONTRIBUTION AND WAGE REPORT                                                                                               UI/TAX & FIELD SERVICES 
                          JSND/UNEMPLOYMENT INSURANCE                                                                                                                           PO BOX 5507 BISMARCK ND 58506-5507 
                          SFN 41270 R. (9-19)                                                                                                                                            PHONE: 701-328-2814 
                                                                                                                                                                      TTY: RELAY ND 800-366-6888 FAX: 701-328-1882 

Employer Name                                                                                             Unemployment Insurance Account Number                                      Tax Rate               % 
Address                                                                                                                                                        Year             Page             of 
                                                                         FIRST QUARTER                    SECOND QUARTER                                       THIRD QUARTER    FOURTH QUARTER
        SSN*              NAME                                           Reported  Corrected              Reported Corrected                     Reported             Corrected Reported         Corrected 

* Include only those wage records that need to be changed or added.
                                                                         FIRST QUARTER                    SECOND QUARTER                                       THIRD QUARTER    FOURTH QUARTER
Quarterly Totals                                                         Reported  Corrected              Reported Corrected                     Reported             Corrected Reported         Corrected 
Total  Wages 
Excess  Wages 

Taxable  Wages 
Net. Diff. Taxable  Wages 
Adj. (Rate x Net Diff.)** 
Explanation of changes: 

Signature                                                                          Title                           Phone Number                                                 Date 
**Interest will be charged at 1.5 percent per month on the unpaid balance. 
*In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North Dakota Century Code 52-02-02. 
This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility purposes and program performance accountability.
                                                                                   Job Service is a equal opportunity employer/program provider. 
                                              Auxiliary aids and services are available upon request to individuals with disabilities upon request. 

Employer Name                         Unemployment Insurance Account Number 
Year                                                                        Page 

                   FIRST QUARTER      SECOND QUARTER     THIRD QUARTER           FOURTH QUARTER
     SSN*     NAME Reported Corrected Reported Corrected Reported Corrected      Reported Corrected