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.