Form  3ADJ Utah Department of Workforce Services, Unemployment Insurance
Rev 0317
                          Unemployment Insurance
                         140 E. 300 S., PO Box 45288, Salt Lake City UT  84145-0288
                          1-801-526-9235         1-800-222-2857 
           The preferred method of filing this report is on-line at our website:
                                http://jobs.utah.gov
                         Amended Employer's Contribution Report
        EMPLOYER NAME & ADDRESS:
                                                                Registration #:

                                                                Quarter:           Year:

                                                                The preferred method of filing this
                                                                report is online at our website:
                                                                                   http://jobs.utah.gov/ui
                          As Reported on
                           E M P L O Y E R ' S
                          CONTRIBUTION REPORT
                          (Form 33H)          CORRECT AMOUNT                       DIFFERENCE

           Total Wages:

           Excess Wages:

           Subject Wages:

        Contribution Due:

                                          PAYMENT SUMMARY                          INSTRUCTIONS
                                                                1.  Use a separate form for each quarter
           Previous Payment This Quarter: $                     amended.
                                                                2.  Total payroll reported on your Form 3 should
           Additional Contribution Due:   $                     show on this form.
                                                                3.  Corrections must be made in the quarter the
                         Interest Due:    $                     wages were actually paid;  i.e. 1st quarter
                                                                amendments cannot be made in the 2nd quarter.
           Additional Contribution Paid:  $                     4.  If individual wages are adjusted, attach a Form
                                                                3HADJ, Amended Wage List.

                         Refund Due:      $

Explanation for Amendment:

Printed Name:______________________________________  Telephone: (_______)______________________

Signature: __________________________________ Title:________________________ Date:__________________