ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration UC-522-FF (5-12)
ADJUSTMENT REPORT
Use this form if you need to make corrections to a previously submitted Unemployment Tax and Wage Report (UC-018).
VERY IMPORTANT: Provide the reason for the adjustment at the bottom of the form (if more space is needed, continue the explanation on the reverse side of the form after printing it). Your adjustment report will be rejected without this information.
If you have questions about completing this form or adjusting wage reports, contact the UI Tax Section at:
Arizona Department of Economic Security
Unemployment Tax – 911B
Accounting Unit
P.O. Box 6028
Phoenix, AZ 85005-6028
Telephone: (602) 771-6601
Fax: (602) 532-5562
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation.
The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service
or activity. Auxiliary aids and services are available upon request to individuals with disabilities. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact the UI Tax office at 602-771-6606; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas a los servicios de DES está disponible a solicitud del cliente.
ADJ
Scan both sides if box is checked. ARIZONA DEPARTMENT OF ECONOMIC SECURITY UC-522-FF (5-12) – Page 2
(Checkbox above is for DES use only.) Unemployment Tax - 911B
ACCOUNT NUMBER P.O. Box 6028, Phoenix, AZ 85005-6028 Adjustment will be rejected unless the reason for it is provided at the bottom of this form. Use reverse side if more space is needed.
– FORMTEXT Phone: 602-771-6601 ( Fax: 602-532-5562
CALENDAR QUARTER ENDING ADJUSTMENT REPORT
EMPLOYER’S NAME ADDRESS (No., Street, City, State, ZIP)
CORRECTION TO REPORT OF WAGES PAID TO INDIVIDUAL EMPLOYEES THIS BOX FOR AGENCY USE ONLY
Employee’s Social Security Number Employee’s Name Amount of Wages Previously Reported Correct Amount
of Wages KEY KEY
Net Increase Net Decrease
0 0 0 0 0 0 0 0 0 Last First Initial Dollars Cents Dollars Cents Dollars Cents Dollars Cents
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CORRECTION TO TAXABLE WAGES & AMOUNTS DUE TOTALS: . .
As Previously Reported As Corrected Net Increase Net Decrease PREPARED BY DATE
Total Wages $ $ $ $
Excess Wages $ $ $ $ VERIFIED BY DATE
Taxable Wages $ – FORMTEXT $ $ $
UI TAX
Adjustment at % (tax rate in effect for quarter indicated above) $ $
UI INTEREST $
Add 1% for each full and/or partial month from delinquent date
YOUR SIGNATURE
JOB TRAINING TAX
Adjustment at 0.10% of Taxable Wages $ $
SPECIAL ASSESSMENT (APPLIES TO CALENDAR QUARTERS IN 2011 AND 2012 ONLY) $ $ YOUR TITLE
Adjustment at 0.40% (2011) or 0.50% (2012) of Taxable Wages
NET ADJUSTMENT $
Underpayment
YOUR PHONE NUMBER
DATE
NET ADJUSTMENT
$
Overpayment
REASON FOR ADJUSTMENT (Required):
Document checksum: 2808326825
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