KANSAS DEPARTMENT OF LABOR                                                                                                                           Continuation sheet _____ of ____
www.dol.ks.gov
                                                                                                                                                     Mail:   Kansas Dept. of Labor
CONTINUATION SHEET – ADJUSTMENT TO QUARTERLY WAGE REPORT                                                                                               P.O. Box 400
K-CNS 112 (Rev. 4-14)                                                                                                                                  Topeka, KS  66601-0400

                          Adjustment to Quarterly Wage Report , K-CNS 111, must accompany this continuation sheet.

                                                                                                                                              M    M    D    D    Y     Y     Y     Y           Q           Y     Y    Y     Y
1. Business                                                     2. Employer                                                       3. Quarter
    Name                                                            Serial Number                                                     Ending
4. Social Security Number  5. Employee Last Name         First Name                           MI Total Wages Reported             Corrected Wages                                 Excess Wages Reported       Excess Wages Corrected

                           8. Total Wages for THIS page                                          $ 0.00                  $ 0.00               $ 0.00   $ 0.00