Department of                        P.O. Box 8007
                                     Little Rock, AR 72203-8007      DWS-ARK-209B
WORKFORCE         SERVICES           Telephone (501) 682-3798        ADJUSTMENT VOUCHER

Date ______________________                                                     Page _________ of ________

DWS Account Number ______________________________

Employer ______________________________________                 Town __________________________________
Amend totals in Part A of my original DWS-ARK-209B for quarter ending ______________________________ as follows:

                                                                REPORTED ON THE      SHOULD HAVE BEEN
                                                                ORIGINAL REPORT                 REPORTED

 Item 2 – Total of all Wages Paid

 Item 3 – Wages in Excess of $

 Item 4 – Taxable Wages

 Contribution Due @     % rate

 Contribution Paid

 Balance due check attached $ ____________ . ______

 Credit amount $ ____________ . ______

Reason for adjustment: _________________________________________________________________________

Amended individual wages reported on DWS-ARK-209B for year and quarter specied below as follows:

                                                                                TOTAL WAGES PAID
 SOC. SEC. NO.                                                  YEAR/
 OF EMPLOYEE                  NAME OF EMPLOYEE                  QTR. REPORTED ON THE            SHOULD HAVE BEEN
                                                                     ORIGINAL REPORT            REPORTED

                                     (For continuation sheet, see reverse side)

Signature ______________________________  Title __________________________  Phone# ______________
DWS-ARK-223 (Rev. 6-06) (PAGE 1 OF 2)

Date _____________________                                                      Page _________ of ________

                                        DEPARTMENT OF WORKFORCE SERVICES
                                        P O BOX 8007 – LITTLE ROCK AR 72203-8007
                                        (501) 682-3798

              DWS-ARK-209B ADJUSTMENT VOUCHER – CONTIUATION SHEET

DWS Account Number ______________________________

Employer ______________________________________       Town __________________________________

                                                                                TOTAL WAGES PAID
SOC. SEC. NO.                                    YEAR/
OF EMPLOYEE   NAME OF EMPLOYEE                   QTR. REPORTED ON THE           SHOULD HAVE BEEN
                                                      ORIGINAL REPORT           REPORTED

DWS-ARK-223(A) (Rev. 6-03) (PAGE 2 OF 2)