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                           North Carolina Department of Commerce 
                           Division of Employment Security 
                           Unemployment Insurance 

              Adjustment to Employer's Quarterly Tax and Wage Report-Continuation 
1. Employer's Name:                               2.       Account Number(s): 
                                                                     
                                                  3.       Quarter/Year:           
4. (a) SSN    (b) Employee's Name                 (c) As Reported               (d) As Corrected 
                                                                                                            
                                                  Total:                        Total:  
                                                                                                            
NCUI 685-A (Rev. 02/2012)