Form 3hadj - Utah Department Of Workforce Services, Unemployment Insurance
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1Form 3HADJ
Utah Department of Workforce Services, Unemployment Insurance
Rev 0214
Unemployment Insurance
140 E. 300 S., PO Box 45288, Salt Lake City UT 84145-0288
1-801-526-9235 option 4
1-800-222-2857 option 4
The preferred method of filing this report is on-line at our website:
Registration #:
EMPLOYER NAME & ADDRESS:
Quarter:
Year:
Note: Only those employees whose wages
are being amended should be included on
this form.
AMENDED WAGE LIST
USE WHOLE DOLLARS ONLY
Wages Reported
Social Security Number
Employee Name
on Wage List
Correct Wages
Difference
First
Middle Init. Last
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Printed Name:___________________________________________ Telephone: (_______)______________________
Signature: ______________________________________ Title:________________________ Date:______________
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