EMPLOYER NUMBER FEIN                                                                         EMPLOYER NAME 
                                             CORRECTION OF WAGE ITEMS                         
                                Alaska Department of Labor and Workforce Development          
                                             Division of Employment and Training Services 
                                             P.O. Box 115509, Juneau, AK 99811-5509 
 
 SOCIAL    EMPLOYEE       QTR. 1   YR ______               QTR. 2   YR ______               QTR. 3   YR ______               QTR. 4   YR ______ 
 SECURITY       NAME      REPORTED                CORRECT  REPORTED                CORRECT  REPORTED                CORRECT  REPORTED                CORRECT 
 NUMBER 
                                                                                                                                
                TOTALS: 
 
EXPLANATION:                                                                                                                                                  
                                                                                                                                                              
I CERTIFY that to the best of my knowledge, the foregoing information is true and correct. 
 
Date:            By:                                        Title:                                     Telephone:                                             

Email: ___________________________________ 
                                                           SOCIAL SECURITY NUMBER            SOC CODE                        GEOGRAPHIC CODE 
                                                                                                                               
 Provide the Social Security Number,  
                                                                                                                               
Standard Occupational Classification (SOC) 
code and Geographic codes for employees                                                                                      
above not previously reported on the 
                                                                                                                             
 Quarterly Contribution Report: 
 
                                                                                                                                TADJ (12/19)