Form Uco-341 - Employer'S Claim For Refund Or Adjustment Of Erroneously Paid Contributions - Ohio Bureau Of Employment Services - 1998

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,
, ss.:
I
t&phone number
66209
OHIO BUREAU OF EMPLOYMENT SERVICES
CONTRIBUTION DEPARTMENT
145 SOUTH FRONT STREET
P.O. BOX 923
COLUMBUS, OHIO 43216-0923
EMPLOYER’S CLAIM for REFUND
or ADJUSTMENT of ERRONEOUSLY
Claim number
not write In this space)
PAID CONTRIBUTIONS
(Do
J
Name
(BUSINESS NAME OF EMPLOYER AS IT APPEARS ON THE QUARTERLY CONTRIBUTION REPORT)
Number and street
State
Zip
City
Amount claimed $
Calendar years for which claim is made
State below the reasons for the alleged overpayment or adjustment; indicate the total wages reported and the contribution paid for
the period for which claim is made. Include all detailed information pertinent to the claim.
(Attach letter size sheets if the space below is not sufficient)
BACK OF EMPLOYER’S COPY FOR INSTRUCTIONS
SEE
IMPORTANT: THIS FORM MUST BE NOTARIZED FOR THIS CLAIM TO BE PROCESSED.
county of
State of
I certify that the foregoing statement and any accompanying statements are true and complete. Sworn
to and subscribed before me this
day of
19
UCO-341 (R 2.99)
BES 0391
Contribution
ORIGINAL COPY: RETURN TO THE BUREAU
DUPLICATE COPY: FOR EMPLOYER’S FILES

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