Adjusted                         Date stamp

                                                                            By   _______________

                                                                            Date  ______________
                Contributions
          45 South Fruit Street                                             Rec'd $_____________
   Concord, New Hampshire 03301-4857
            Phone (603) 224-3311 Fax (603) 225-4323
          www.nhes.nh.gov

                  TAX AND WAGE REPORT ADJUSTMENT FORM
                                          (A separate form must be submitted for each quarter)

Employer Name:                                                                                  Account #
                                                                                                Name Control 

                                                                                              Quarter Ending ____________________

Request is hereby made for an adjustment to my account for the following reason(s): _______________________________

CORRECTIONS - PART 1 (Tax Report)                  1st Month                     2nd Month                        3rd Month
Line 7

CORRECTIONS - PART 1 (Tax Report)
Tax Report Line   Item                             Amount Previously        Correct Amount                   Difference (+ or -)
                                                   Reported
Line 8            Total Wages 
Line 9            Excess Wages
Line 10           Taxable Wages
Line 11           UI Rate
Line 12           AC Rate 
Line 13           Total Tax Due
* Interest should be calculated at 1% per month from the quarterly due date                   *Interest Due
(Make check payable to: State of NH - UC)                                   Balance or Credit Due

CORRECTIONS - PART 2 (Wage Report)
Social Security #                         Employee Name                     Amount Previously                Correct Amount
                                                                                              Reported

Signature                                 Title                             Date                             Phone