MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                                              EAU ADJ 4A 
               DIVISIONOF EMPLOYMENT SECURITY 
               P.O. Box 59, Jefferson City, MO 65104-0059 
               CONTRIBUTION & WAGE ADJUSTMENT REPORT 

                                 Adjustments  may be submitted online at uinteract.labor.mo.gov. 

                                       STATUTE OF LIMITATIONS 
               A claim for refund or credit must be filed within three years of the due date of the quarter being adjusted.       

1. Employer Name and Address                                          2. Missouri Employer Account Number            3. Contribution Rate 

                                                                      4. Reason for Claiming Adjustment              Mark Quarter and Enter Year 
                                                                      Note: Adjustment will not be accepted if this 
                                                                      portion is not completed.                      1st            2nd 
                                                                                                                     3rd            4th 
                                                                                                                     Year 

                                       A. Previously Reported for          B. Correct Totals            C. Difference - Over or   Audit Block 
                                                              Quarter                                        Under Reported      AGENCY USE ONLY 
5. Total Wages Paid
6. Wages in Excess of $
7. Taxable Wages
8. Contributions Due
9. Interest Due
10. Total Payment Due
11. Additional Amounts Due
12. Credit Due

Enter below ONLY those employees whose wages or Social Security Numbers are being corrected. 
NOTE: If you are adjusting more than seven employees, list the additional items on a separate page with the same format, including employer name and 
      account number. 
                             14.       Worker's Name                                                         Total Wages Paid                    17. 
13. Worker's                           Middle 
                                                                                                                                          Multi- 
Social Security Number           First Initial                        Last 15. As Reported                           16. As Corrected
                                                                                                                                          State 

18. Totals
19. Differences  ( +  or  - )

I certify that the information I provided is true and correct. 
20. Signature                                                                                           Date 

Title                                                                                                   Phone Number (Area Code) 

                                       (READ FOLLOWING INSTRUCTIONS)                                                             MODES-4A (04-17)
                                                                                                                                          UITax 

             Instructions for Preparation of Contribution and Wage Adjustment Report 

This adjustment report is to be used for the purpose of adjusting summary total and wage data previously reported. A separate report is to 
be used for each quarter to be adjusted and for each separate account number assigned. 

It is recommended Items 13 through 19 be completed prior to completing Items 5 through 12. 

1. Type or print employer’s name and address.
2. Enter the 10-digit Missouri Division of Employment Security employer account number.
3. Enter the contribution rate for the calendar quarter being adjusted.
4. Enter the full facts to support the claim for adjustment. Example: Do not say “reported in error.” Explain why the wages were reported
in error. Mark Quarter and Enter Year for report being adjusted.
5-10. Column A. Enter the totals previously reported on the employer’s Quarterly Contribution and Wage Report, or
                              latest Contribution and Wage Adjustment Report for the quarter. 
             Column B. Enter the correct totals which should have been reported for the quarter. 
             Column C. Enter the difference between Column A and Column B. 
The taxable wage base in Missouri from 2010 to the current calendar year has been $13,000. Based on the current taxable wage base, the 
first $13,000 in wages paid to a worker by an employer is taxable. 

                        SAMPLE WORKSHEET FOR COMPUTING EXCESS WAGES  (Sample based on $13,000) 
                            FIRST QUARTER                SECOND QUARTER                THIRD QUARTER                   FOURTH QUARTER 
Social                      Total     Excess             Total   Excess           Total       Excess                   Total     Excess 
Security                    Wages for of      Taxable  Wages for   of    Taxable  Wages for   of              Taxable  Wages for of         Taxable 
Number       Name           Quarter   $13,000 Wages Quarter      $13,000 Wages    Quarter     $13,000         Wages    Quarter  $13,000     Wages 
111-111-1111 John Doe       12,000.00 -0-     12,000.00  12,000.00  11,000.00  1,000.00  12,000.00  12,000.00 -0-      12,000.00  12,000.00 -0- 
222-222-2222  Mary Doe      4,000.00  -0-     4,000.00  4,000.00   -0-   4,000.00 4,000.00    -0-             4,000.00 4,000.00  3,000.00  1,000.00 
             Totals for     16,000.00 -0-     16,000.00  16,000.00  11,000.00  5,000.00  16,000.00  12,000.00  4,000.00  16,000.00  15,000.00  1,000.00 
             Quarter        (4)       -5      (6)        (4)       -5    (6)      (4)         -5              (6)      (4)       (5)        -6
             Enter on Line: 

11. If this report indicates additional contributions are due, this figure would be Item 10, Column B less Column A. (Make remittance
payable to the Division of Employment Security.)
12. If this report indicates a credit is due, this figure would be Item 10, Column A less Column B.
13. Enter the worker’s Social Security Number.
14. Enter the worker’s name (first name, middle initial and last name) whose wages are being adjusted.
15. Enter the Total Wages Paid previously reported for the worker for the quarter.
16. Enter the correct Total Wages Paid to the worker for the quarter.
17. Mark the box for each employee your business reported to another state’s employment security agency during the calendar year. You
may use these wages to compute the wages paid in excess of the taxable wage base.
18. Enter the total of all entries made in Items 15 & 16.
19. Enter the difference between Items 15 & 16. If Item 15 is more than Item 16, a minus sign should precede the difference. If Item 15 is
less than Item 16, a plus sign should precede the difference.
20. This form must be signed by a responsible and duly authorized person.

If there are more than seven workers’ wages to be adjusted, a separate page with the additional information using the same format as 
above, including employer name and account number, should be completed. For assistance in completing this form, please call 
573-751-1995 then select option 2.

Mail original of this form to:  ATTN: Employer Account Unit 
                                  Division of Employment Security 
                                  P.O. Box 59 
                                  Jefferson City, MO 65104-0059 

IMPORTANT: If needed, call 573-751-1995 for assistance in the translation and understanding of the information in this document.  
¡IMPORTANTE!: Si es necesario, llame al 573-751-1995 para asistencia en la traducción y entendimiento de la información en este documento. 
             Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and service 
              are available upon request to individuals with disabilities.   TDD/TTY: 800-735-2966   Relay Missouri: 711 
                                                                                                                             MODES-4A-2 (04-17)