Free lb0459R1.06NewAddress.pmd - Tennessee

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Claim No.______________
TENNESSEE DEPT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER ACCOUNTS OPERATIONS EMPLOYER ACCOUNTING UNIT 220 FRENCH LANDING DRIVE NASHVILLE TN 37243 (615)741-1619 FAX (615)741-7214

Date Rec'd ____/____/____

Examined ________________________________________ Wage Records Corrected ____________________________ Approved _________________________________________ Adj. Prepared by ________________ Date ____/____/____

CLAIM FOR ADJUSTMENT OR REFUND

A claim for adjustment is hereby made in accordance with Section 50-7-404(F) of the Tennessee Employment Security Act because of premiums erroneously paid to the Tennessee Department of Labor and Workforce Development.

Name of Employer _________________________ Street Address ____________________________ City and State _____________________________ Date Premiums Paid ________________________

State Account Number _________________________ Federal I.D. Number ___________________________ Quarter(s) and Year(s)__________________________ Amount claimed as refund _______________________

In the space below explain why the wages are being decreased.

List employees erroneously reported showing by quarter the amount of wages reported and the amount that should have been reported. Attach additional sheets if necessary. If employee(s) should be reported to another state, please provide proof of report and payment to that state.
Social Security Number Name of Employee Qtr. Total Wages Reported Correct Total Wages Diff. Taxable Wages Reported Correct Taxable Wages Diff.

It is understood that any adjustment allowed will be made in connection with subsequent premium payments, without interest, unless such an adjustment cannot be made, in which case a refund will be made, without interest. Under the penalties of perjury I declare that the statements made in support of this claim are true, correct and complete, to the best of my knowledge and belief.
Signature of Preparer _______________________________ Title ________________________ Date _____/_____/_____ Preparer's Phone Number ____________________________
LB-0459 (R. 1/06)

If prepared by Agency Representative Signature ______________________________________ Date _____/_____/_____
RDA 2438