LOUISIANA WORKFORCE COMMISSION                            AMENDED
  OFFICE OF UNEMPLOYMENT INSURANCE ADMINISTRATION
  P.O. BOX 94100
  BATON ROUGE, LOUISIANA 70804-9186
                                                                                                  CONTINUATION
  ATTN: TAX ACCOUNTING/ADJUSTMENTS
  (225) 342 -2961   FAX (225) 346-6071                                                            WAGE LISTING
  This document is semi-interactive.  It may be filled out on-line but must be mailed or faxed in.
   Employer Name & Address                                      State ID. Number                  Year/Quarter

                                                              This form is a continuation of Lines 12 thru 15 of the 
                                                              Quarterly Wage & Tax Report - Amendment Form.

  12. Soc. Sec. Number     13. Employee Name                  14.  Original Total Wages           15.  Amended  Total Wages

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