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Instructions: Reports must be in dark ink. DWD images reports when received. Using light ink or a pencil may prevent the report
from being processed. Reports must be legible. Print your responses using block letters.
You may need to file more than one page if you are correcting more than 2 workers. Report only the workers that need to be corrected.
You should not include workers that were correctly reported on the original quarterly report.
For each line of original information, you must have a line of corrected information. If there are not changes for a worker, do not
include reporting for that worker.
If you reported the worker on the original report, you should have information in all columns, A – R, even if you are only changing
the information in one column. If the information in the “original” line does not match the original report, this report will not be
processed.
If you need to add a worker that you left off the original report, write “BLANK” in the SSN column (G) on the original information
line. If you need to remove a worker, write 0 (zero) in the gross wages column (O) on the corrected information line.
In part A, write down the quarter number and the year for the period you are correcting. This should match the original report.
In part B, write down the total number of workers being corrected. Include all pages of the report being filed. Include multiple pages
if there are more than 2 workers that need to be corrected, added, or removed.
In part C, write down the total amount of payroll distributed to workers during the calendar quarter after the corrections. Include all
pages of the report being filed.
In part D, write down a valid, employer, contact name and telephone number.
In part E, write down the SUTA account number assigned by DWD to the employer’s account and the FEIN that will be used on the
employee’s W-2 or 1099 for the current year. If the employer operates under more than one FEIN, complete a new page for each
FEIN.
In part F, write the page number for this page of your report and the total number of pages that you are reporting.
In part G, write down the Social Security Number or ITIN of the employee first as originally reported and then the correct SSN or
ITIN. If you left the person off your original report, write “BLANK” on the original information line.
In part H, write down the employee’s last name first as originally reported and then the correct last name.
In part I, write down the employee’s first name first as originally reported and then the correct first name.
In part J, write down the employee’s middle initial first as originally reported and then the correct middle initial– leave this blank if
the employee does not have a middle name.
In part K, write down the worker’s start date with this employer first as originally reported and then the correct start date.
In part L, write down the employee’s SOC (Standard Occupational Classification) code first as originally reported and then the
correct SOC code.
In part M, write down the ZIP Code where the employee is working for the employer first as originally reported and then the correct
ZIP Code where the employee is working for the employer in Indiana.
In part N, write down the type of employment for this employee first as originally reported and then the correct type of employment.
In part O, write down the total wages paid to the employee that are subject to unemployment first as originally reported and then the
correct total wages. This is the Gross wage amount, not the taxable wage amount. To remove someone from your report, write down
0 on the corrected information line.
In part P, write down a Y or N first as originally reported and then the correct code to indicate if the worker was active during the
payroll period that contained the 12 thday of the first month of the quarter.
In part Q, write down a Y or N first as originally reported and then the correct code to indicate if the worker was active during the
payroll period that contained the 12 thday of the second month of the quarter.
In part R, write down a Y or N first as originally reported and then the correct code to indicate if the worker was active during the
payroll period that contained the 12 thday of the third month of the quarter.
Write down the reason why the report needs to be corrected. Example reasons: Correcting SSN. Correcting Wages. Adding SOC
code. Correcting start date. Add employee left off of original report.
If you have any questions, call DWD at 800-891-6499 option 2 for Employer Assistance or refer to the Employer Handbook.
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