Form  3HADJ   Utah Department of Workforce Services, Unemployment Insurance
Rev 0214
                                     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

                                                                     Registration #:
        EMPLOYER NAME & ADDRESS:

                                                                     Quarter:       Year:

                                                                     Note:  Only those employees whose wages
                                                                     are being amended should be included on
                                                                     this form.

AMENDED WAGE LIST                                                    USE WHOLE DOLLARS ONLY
                                                           Wages Reported
        Social Security Number       Employee Name         on Wage List             Correct Wages Difference
                               First Middle Init. Last

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Printed Name:___________________________________________  Telephone: (_______)______________________

Signature: ______________________________________ Title:________________________ Date:______________