Esd-Ark-223 - Arkansas Employment Security Department

Esd-Ark-223 - Arkansas Employment Security Department - 2001

ESD-ARK-223

Date __________________

(Rev. 9-01)

Page _________ of ______

ARKANSAS EMPLOYMENT SECURITY DEPARTMENT

P O BOX 8007 - LITTLE ROCK AR 72203-8007

(501) 682-3798

ESD-ARK-209B ADJUSTMENT VOUCHER

ESD Account Number _______________________________

Employer _______________________________________

Town ____________________________________

Amend totals in Part A of my original ESD-ARK-209B for quarter ending _______________________________ as follows:

REPORTED ON THE

SHOULD HAVE BEEN

ORIGINAL REPORT

REPORTED

Item 2 - Total of all Wages Paid

Item 3 - Wages in Excess of $

Item 4 - Taxable Wages

Contribution Due @

% rate

Contribution Paid

Balance due check attached $ ____________ . ______

Credit amount $ ____________ . ______

Reason for adjustment: ___________________________________________________________________________

Amend individual wages reported on ESD-ARK-209B for year and quarter specified below as follows:

SOC. SEC. NO.

YEAR/

TOTAL WAGES PAID

OF EMPLOYEE

NAME OF EMPLOYEE

QTR.

REPORTED ON THE

SHOULD HAVE BEEN

ORIGINAL REPORT

REPORTED

(For continuation sheet, see reverse side)

Signature ___________________________ Title ___________________________ Phone#__________________

Esd-Ark-223 - Arkansas Employment Security Department - 2001