Form 226 - Statement To Amend Contribution And Wage Report
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2226 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 information is required. Separate statement must
be filed for each quarter.
Reason for adjustment:
FOR AGENCY USE ONLY
TAX RATE
EMPLOYER NAME
INTEREST RATE IF PAID
WITHIN 30 DAYS
ACCOUNT NUMBER
QUARTER ENDING:
APPLIC QTR
ITEM
AMOUNT REPORTED
AMENDED AMOUNT
DIFFERENCE (+ 0R -)
TOTAL WAGES
TOTAL WAGES
NON TAXABLE WAGES
NON TAXABLE WAGES
TAXABLE WAGES
TAXABLE WAGES
CONTRIBUTIONS (TAXES)
REMITTANCE
WAGE DETAIL
SSN
EMP NAME
REPORTED
AMENDED
DIFFERENCE (+ 0R -)
REPORT TYPE
BOTH
PENALTY
INTEREST
RESP ACTIVITY
RESP OPID
REC DATE
DIS EDITS
YOUR TOTAL REMITTANCE MADE PAYABLE TO "DC DOES" , 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
609 H STREET, N.E. ROOM 353-367
VOICE
(202) 698-7550
ACCOUNT NUMBER
WASHINGTON, D.C. 20002-4347
FAX
(202) 698-5706
CHECK NUMBER
I 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:
[ ] REFUND REQUESTED
X
[ ] APPLY CREDIT
SIGNATURE
PRINT NAME
TITLE
DATE
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