Fillable QUARTERLY CONTRIBUTION AND WAGE ADJUSTMENT FORM (California)

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QUARTERLY CONTRIBUTION AND WAGE ADJUSTMENT FORM (California)

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DE 9ADJ Rev. 3 (7-13) (INTERNET) Page 1 of 2 CU
QUARTERLY CONTRIBUTION AND
WAGE ADJUSTMENT FORM
STATUTE OF LIMITATIONS
A claim for refund or credit must
be filed within three years of the
last timely filing date of the quarter
being adjusted.
You can file this adjustment form online through the Employment Development Department’s (EDD) e-Services for Business.
Please visit our website at www.edd.ca.gov. See Instructions for Completing t
he Quarterly Contribution and Wage
Adjustment Form (DE 9ADJ-I) for completing this form.
SECTION I: (PLEASE PRINT)
BUSINESS NAME
ADDRESS
CITY, STATE, ZIP CODE
YEAR / QUARTER
EMPLOYER ACCOUNT NO.
REASON FOR ADJUSTMENT
SECTION II:
ADJUSTMENT TO WAGES AND CONTRIBUTIONS
(1)
Previously reported
(2)
(3)
DIFFERENCES
Debit/(Credit)
A. TOTAL SUBJECT WAGES .................................................
B. UNEMPLOYMENT INSURANCE (UI) Taxable Wages ........
C. STATE DISABILITY INSURANCE (SDI) Taxable Wages ....
D. EMPLOYER’S UI CONTRIBUTIONS (UI Rate 0.00 % times B) ...
0.00E. EMPLOYMENT TRAINING TAX (ETT Rate % times B) ...
F.
STATE DISABILITY INSURANCE*
* Includes Paid Family Leave amount.
(SDI) Withheld (SDI Rate
0.00 % times C; complete Box 1 below if credit on row F.) ..
G
. PERSONAL INCOME TAX (PIT) Withheld (Complete
Box 2 below if credit on line G.) ...........................................
H. SUBTOTAL (Lines D, E, F, and G) . ..............................
I. Penalty (Refer to instructions on DE 9ADJ-I)
..................
................................................................................................
................................................................................................
J. Interest (Refer to instructions on DE 9ADJ-I)
..................
K. Erroneous SDI Deductions not refunded (See Box 1, NOTE below)
...............
................................................................
L. Less contributions and withholdings paid for the quarter
.
................................................................................................
M. Total taxes due or overpaid
(H2 + I + J + K) - L
................................................................................................
.............
BOX 1. STATE DISABILITY INSURANCE OVERPAYMENTS
(Must be completed for credit to be allowed.)
1. Was the credit claimed in column 3 withheld from the wages of employee(s)? ...............................................................
Yes No
If yes, has this amount been refunded to employee(s)? .................................................................................................
Yes
No
If not refunded: employee(s) no longer employed, unable to locate.
NOTE: The EDD cannot refund these contributions to you unless you first refund the erroneous deductions to the employee(s).
(List each employee name, Social Security Number, and amount of SDI not refunded.)
BOX 2. PERSONAL INCOME TAX OVERPAYMENTS
(Must be completed for credit to be allowed.)
If you paid the Employment Development Department
(EDD) more than the amount of California PIT withheld from wages of employee(s),
you can adjust the amount reported by using this form. The
EDD will allow credit adjustments prior to the issuance of Forms W-2. If you
have already issued Forms W-2, please read the additional information on page 2 before proceeding.
1. Was the credit claimed in column 3 withheld from the pay of employee(s)? ...................................................................
Yes No
If yes, has this credit been refunded to employee(s)? ....................................................................................................
Yes
No
2. Was the credit claimed in column 3 included on Forms W-2 issued to employee(s)?
Yes
No
Be sure to sign this declaration: I declare that the information herein is true and correct to the best of my knowledge and belief.
Signature Title
(Owner, Accountant, Preparer, etc.)
Phone
( )
Date
SIGN AND MAIL TO: Employment Development Department / P.O. Box 989073 / West Sacramento, CA 95798-9073
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Page 2 of 2
QUARTERLY CONTRIBUTION AND WAGE ADJUSTMENT FORM
BUSINESS NAME
EMPLOYER ACCOUNT NO.
SECTION III: QUARTERLY WAGE AND WITHHOLDING ADJUSTMENTS
Enter amounts that should have been reported; if unchanged, leave field blank. Correcting the Social Security Number or Name
requires two entries. See Instructions for Completing the Quarterly Contribution and Wage Adjustment Form (DE 9ADJ-I),
Section III, for additional information and instructions.
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
DE 9ADJ Rev. 3 (7-13) (INTERNET)
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QUARTERLY CONTRIBUTION AND WAGE ADJUSTMENT FORM (California)

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Completed 8 December 2021

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