Form Ui-3b - Employer'S Quarterly Adjustment Report - 2005

UI-3B

R03/05

MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY

Post Office Box 22781

Jackson, Mississippi 39225-2781

Telephone Number: (601)321-6063

EMPLOYER'S QUARTERLY ADJUSTMENT REPORT

If the Social Security number, name or wages of one or more workers were omitted from or erroneously

reported in a wage report, each such error should be corrected on this form. Complete a separate UI-3b for each

quarter requiring a correction.

ADJUSTMENT FOR THE QUARTER ENDING

PAGE NO.

OF

PAGES FOR THIS QUARTER

MDES ACCOUNT NUMBER

TAX RATE

QTR/YR

EMPLOYER'S NAME

WAGE ADJUSTMENTS TO UI-3

SOCIAL SECURITY

2.

3. TOTAL WAGES PAID

4. TOTAL WAGES PAID

DO NOT USE

NUMBER

EMPLOYEES NAME

THIS QUARTER

THIS QUARTER SHOULD

THIS COLUMN

BE

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

5. TOTALS

$

$

6. DIFFERENCES

(Column 3 Total - Column 4 Total )

$

7. REASON FOR ADJUSTMENT

SIGNATURE

DATE

COLUMN A

COLUMN B

DIFFERENCE OF

CONTRIBUTIONS ADJUSTMENT TO UI-2

COLUMN A & COLUMN B

AS REPORTED

SHOULD BE

8. TOTAL GROSS WAGES PAID THIS QUARTER

.

.

.

9. NON-TAXABLE WAGES PAID THIS QUARTER

.

.

.

10. TAXABLE WAGES PAID THIS QUARTER

.

.

.

11. UI CONTRIBUTIONS DUE

.

.

.

12. TRAINING CONTRIBUTIONS DUE

.

.

.

13. TOTAL CONTRIBUTIONS DUE

)

.

.

.

(add item 11 & 12

14. INTEREST ON ITEM 13

.

.

.

15. DAMAGES ON ITEM 13

.

.

.

16.TOTAL PAYMENT DUE

.

.

.

REASON FOR ADJUSTMENT

MDES ACCOUNT NUMBER

TAX RATE

QTR/YR

EMPLOYER'S NAME AND ADDRESS

I certify that the information contained in this report and any subsequent pages attached is true and correct and that no part of the tax was or is to be deducted from the worker's

wages.

Telephone Number

Signature of individual making return or responsible therefore

Title

Date