Maryland Department of Labor
1-800-492-5524 Ext. 2410
Local: 410-767-2410
Federal Number: ________ - __________________________ Fax: 410-767-2680
Request for Wage Adjustment
(A Separate Form Must Be Submitted For Each Quarter)
Gentlemen:
Request is hereby made for an adjustment to my account for the following reason(s):
|AMOUNT OF REMITTANCE (If Applicable) $ |FOR THE QUARTER ENDING: |
|EMPLOYER ACCOUNT NUMBER: 00 _____________________________ | |
|ITEM |AMOUNT REPORTED |CORRECTED AMOUNT |DIFFERENCE (+ OR -) |
|Total Wages | | | |
|Excess Wages | | | |
|Taxable Wages | | | |
|X Tax Rate |. __________ |. __________ |. __________ |
|Contributions (Tax) | | | |
|*Interest should be calculated at 1.5% per month from the quarterly due date. INTEREST DUE |$ |
|(Make your check payable to Maryland Unemployment Insurance Fund) TOTAL |$ |
WAGE DETAIL
(If more space is needed, please send on additional blank sheets)
|SOCIAL SECURITY NUMBER |EMPLOYEE NAME |AMOUNT REPORTED |CORRECT AMOUNT |DIFFERENCE |
| | | | |( + OR - ) |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
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Firm Name:
Signature:
(State whether individual, owner, partner – title, if officer of Corporation)
Date:
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FOR INTERNAL USE ONLY
_____________________________________________
(Account Adjusted By)
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[pic]
Larry Hogan, Governor Boyd K. Rutherford, Lt. Governor
DLLR/DUI 21 Web (Revised 1-19)
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