MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                          EAU ADJX
     DIVISION OF EMPLOYMENT SECURITY                                                                      CASE ID
     P.O. Box 59, Jefferson City, MO 65104-0059
     CONTRIBUTION & WAGE ADJUSTMENT REPORT FOR QUARTER ENDING
     Adjustments may be submitted online at www.ustar.dolir.mo.gov by registering with the password printed on the quarterly report.
                                                             STATUTE OF LIMITATIONS
             A claim for refund or credit must be filed within three years of the due date of the quarter being adjusted.
1. Employer Name and Address                                     2. Missouri Employer Account Number      3. Contribution Rate

                                                                 4. Reason for Claiming Adjustment
                                                                 Note: Adjustment will not be accepted if this portion is not completed.

                                                             A.  B.                                 C.                   Audit Block
                                            Previously Reported  Correct                   Difference - Over or    AGENCY USE
                                            for Quarter          Totals                    Under-Reported                           ONLY
  5. Total Wages Paid
  6. Wages in Excess of $
  7. Taxable Wages
  8. Contributions Due
  9. Interest Due
10. Total Payment Due
11. Additional Amounts Due
12. Credit Due
Enter below ONLY those employees whose wages or social security number are being corrected.
NOTE:  If you are adjusting more than five (5) employees, list the items on a separate page with the same format, including employer
             name and account number.
13.          Worker's       14.            Worker's Name                           Total Wages Paid                      Audit Block
     Social Security         First   Middle                      15.          As           16.          As         AGENCY USE
     Number                  Initial Initial                 LastReported                      Corrected                            ONLY

17. TOTALS
18. DIFFERENCES  ( +  or  - )
I certify that the foregoing information is true and correct.
19. Signature                                                                              Date

Title                                                                                      Phone Number (Area Code)

                                            (READ FOLLOWING INSTRUCTIONS)
                                                                                                               MODES-4A (03-09)  AI
                                                                                                                                        Cont.

TaxableWages500.00-0-500.00(6)

of(5)      
Excess$12,50012,000.003,500.0015,500.00
MODES-4A-2 (03-09)  AI
FOURTH QUARTER
(4)      
Total4,000.00
Quarter
Wages for12,000.0016,000.00

-0-(6)      
TaxableWages4,000.004,000.00

of-0-(5)
Excess$12,50012,000.0012,000.00
THIRD QUARTER
(4)      
Total4,000.00
Wages forQuarter12,000.0016,000.00

500.00(6)      
TaxableWages4,000.004,500.00

of-0-(5)
Excess$12,50011,500.0011,500.00
SECOND QUARTER
(4)      
TotalQuarter12,000.004,000.0016,000.00
Wages for

(6)      
TaxableWages12,000.004,000.0016,000.00

Instructions for Preparation of Contribution and Wage Adjustment Reportof-0--0--0-(5)
SAMPLE WORKSHEET FOR COMPUTING EXCESS WAGES  (Sample based on $12,500)Excess$12,500
ATTN: Employer Accounts UnitDivision of Employment SecurityP.O. Box 59Jefferson City, MO 65104-0059
FIRST QUARTER
(4)      
Total4,000.00
Quarter
       Adjustment Report for the quarter.Wages for12,000.0016,000.00

Name
John DoeMary Doe
                     Column B. Enter the correct totals which should have been reported for the quarter.        Column C. Enter the difference between Column A and Column B.
Enter on Line:

    Social  Security   Number               Totals for Qtr.
This adjustment report is to be used for the purpose of adjusting summary total and wage data previously reported. A separate report is to be used for each quarter to be adjusted and for each separate account number assigned.Enter at the top of form the ending date of the calendar quarter for which the report is being filed. It is recommended Items 13 through 18 be completed prior to completing Items 5 through 12.1.  Type or print employer’s name and address.2.  Enter the 14-digit Missouri Division of Employment Security employer account number.3.  Enter the contribution rate for the calendar quarter being adjusted.4.  Enter the full facts to support the claim for adjustment. As an example, do not say “reported in error” but explain why the wages were reported in error.5, 6, 7, 8, 9 & 10.   Column A. Enter the totals previously reported on the employer’s Quarterly Contribution and Wage Report, or latest Contribution and WageThe first $11,000 in wages paid to a worker by an employer is taxable in 2006 & 2007. The wage base for calendar year 2008 is $12,000.00. For 2009 the wage base is $12,500.00.111-11-1111222-22-222211.  If this report indicates additional contributions are due, this figure would be Item 10, Column B less Column A. (Make remittance payable to the Division of Employment       Security.)12.  If this report indicates a credit is due, this figure would be Item 10, Column A less Column B.13.  Enter the worker’s social security number.14.  Enter the worker’s name (first initial, middle initial and surname) whose wages  are being adjusted.15.  Enter the Total Wages Paid previously reported for the worker for the quarter.16.  Enter the correct Total Wages Paid to the worker for the quarter.17.  Enter the total of all entries made in Items 15 & 16.18.  Enter the difference between Items 15 & 16. If Item 15 is more than Item 16, a minus sign should precede the difference. If Item 15 is less than Item 16, a plus sign        should precede the difference.19.  This form must be signed by a responsible and duly authorized person.If there are more than seven workers’ wages to be adjusted, a separate page with the same format as above, including employer name and account number, should be completed. For assistance in completing this form, please call (573) 751-1995.Mail original of this form to: