Amended Return Request

Amended Return Request
Company Name*
What is the nature of your adjustment? Select all that apply:*

Missing/Incorrect EarningsIncorrect Tax State/LocalIncorrect Taxable Wages/Tax AmountsIncorrect Social Security NumberOther
Does this adjustment affect any quarters in prior calendar years?*

Yes, this affects tax returns in prior calendar yearsNo, this adjustment only affects tax returns in the current year
Select which tax quarters are affected in the current year:*

Q1 (1/1 - 3/31)Q2 (4/1 - 6/30)Q3 (7/1 - 9/30)Q4 (10/1 - 12/31)No quarters in the current year need adjustments
Enter the affected tax year:*
Select which tax quarters are affected in the year listed above:*

Q1 (1/1 - 3/31)Q2 (4/1 - 6/30)Q3 (7/1 - 9/30)Q4 (10/1 - 12/31)
Prior Year Adjustment Notes:
- For prior year adjustments, affected employees may need a Form W-2C, and in addition to amendments to quarterly returns, Federal Unemployment return (Form 940) may need to be amended as well.
- If Form W-2C is required for any employee, a PDF copy will be provided to you (the employer) to distribute to your employees. If the employee has already filed their taxes for the year being adjusted, they may need to amend their personal tax filing.
How many employees need to be adjusted?*
Upload a list of employees who need to be adjusted (or list in box below):

Cancelof
Please include any additional details below:

Adjustment Fees
Adjustment Processing (per pay date)	$50
Amended Tax Returns (per return)	$200
Form W-2C Base Fee (if any W-2C forms are required)	$150
Form W-2C Forms (per form)	$50

Submitted By:*

First NameLast Name
Submitter Email*
example@example.com
By submitting this form, I approve the requested tax adjustment and associated fees as outlined in this form. I have reviewed and have noted any special instructions. Therefore, I assume any related liability in the event that the information provided is found to be inaccurate.
Should be Empty:

Prior Year Adjustment Notes: