Statement To Amend Contribution And Wage Report Form
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1226 REV 4/00
STATEMENT TO AMEND CONTRIBUTION AND WAGE REPORT
This statement must be filed in duplicate and must bear a signature and telephone number in case further intormation is required, Separate statement
must be filed for each quarter.
FOR AGENCY USE ON LY
Reason for adjustment:
Employer name and account number:
TAX RATE
EMPLOYER NAME,
INTEREST RATE IF PAID
WITHIN 30 DAYS
ACCOUNT
NUMBER
QUARTER ENDING:
APPLIC QTR
DIFFERENCE (+ OR -)
ITEM
AMOUNT REPORTED
AMENDED AMOUNT
TOTAL WAGES
TOTAL WAGES
NON TAXABLE WAGES
NON TAXABLE WAGES
TAXABLE WAGES
TAXABLE WAGES
.
.
CONTRIBUTIONS (TAXES)
REMITTANCE
.
.
WAGE DETAIL
.
.
SSN
EMPNAME
REPORTED
AMENDED
DIFFERENCE (+ OR -)
REPORTTYPE
BOTH
.
PENALTY
INTEREST
RESP ACTIVITY
RESP OPID
REC DATE
DIS EDITS
YOUR TOTAL REMITTANCE MADE PAYABLE TO -OC 0093-, MUST INCLUDE APPLICABLE INTEREST AND OR PENALTY. TO CALCULATE YOUR TAX DUE. MULTIPLY THE TAXABLE WAGES IN THE
BANK NAME
DIFFERENCE COLUMN BY YOUR TAX RATE. ADD 1.5% OF THE ADDITIONAL AMOUNT DUE FOR EACH MONTH OR FRACTION THEREOF FROM THE DATE DUE UNTIL PAID,
MAIL TO:
DC DOES
500 C STREET NW ROOM 501
VOICE
202 724-7457
ACCOUNT NO.
WASHINGTON, DC 20001
FAX
202 724-7474
CHECK NO
CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND CORRECT AND THAT NO PART OF THE TAX WAS OR IS NOT TO BE DEDUCTED
FROM THE WORKERS WAGES.
TOTAL REMITTANCE
IF ADJUSTMENTS RESULTS IN A CREDIT:
X.
[ ] REFUND REQUESTED
[ I
APPLY CREDIT
SIGNATURE
PRINT NAME
TITLE
DATE
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