Amended Tax & Wage Report (Form 5208D)
EMAIL to UIFiles@ESD.WA.GOV - or - FAX to 800-794-7657
MAIL TO:
EMPLOYMENT SECURITY DEPARTMENT
ATTN: TAX ACCOUNTING
PO BOX 9046, OLYMPIA, WA 98507-9046
Social Security #
Name of Employee
Hours
Wages
AS REPORTED
Wages
CORRECT AMOUNT
1
2
3
4
5
6
7
8
9
10
AS REPORTED
CORRECT AMOUNT
12) TOTAL GROSS WAGES
13) EXCESS WAGES
14) TAXABLE WAGES
15) UI TAX DUE FOR THIS QUARTER
16) EAF
17) TOTAL TAX AMOUNT DUE
18) LATE PAYMENT PENALTY
19) INTEREST
20) LATE REPORT PENALTY
21) PRIOR BALANCE OR CREDITS
22) AMOUNT DUE
23) AMOUNT REMITTED
*REASON FOR
ADJUSTMENT
Hours
(MANDATORY)
EMS
5208 D (Rev. 10/20)
CC 7540-032-822
M M D D Y Y
AMEND ONLY ONE QUARTER PER FORM - YOU MAY MAKE COPIES OF THIS FORM BEFORE USING
1) FEDERAL ID NUMBER (9-DIGIT) 2) UBI NUMBER (12-DIGIT) 3) EFFECTIVE QUARTER ENDING DATE
4) BUSINESS NAME
5) ESD NUMBER (12-DIGIT)
6) PREPARER’S INFORMATION
FIRST NAME LAST NAME
PHONE FAX
AREA CODE NUMBER EXT AREA CODE NUMBER
EMAIL ADDRESS
Hours
0
0 0
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