Fillable Printable Quarterly Contribution And Wage Adjustment Form (De 9Adj)
Fillable Printable Quarterly Contribution And Wage Adjustment Form (De 9Adj)
Quarterly Contribution And Wage Adjustment Form (De 9Adj)
DE9ADJ Rev.3 (7-13) (INTERNET)Page 1 of 2CU
QUARTERLY CONTRIBUTION AND
WAGEADJUS TMENT FORM
You can file this adjustment form online thr ough the Employment Development Department’s (EDD) e-Services for Busi ness.
Please visit our w ebsite at www.edd.ca.gov.See Instructions for Completing theQuar terly Contribution and W age
Adjustment Form (DE 9ADJ-I) for completing t his form.
SECTION I: (PLEASE PRINT)
YEAR / QUARTER
BUSINESS NAME
EMPLOYER ACCOUNT NO.
ADDRESS
CIT Y, ST AT E, ZIP CODE
REASON FOR ADJUSTMENT
(1)
(2)
(3)
SECTION II:
DIFFERENCES
ADJUSTME NT TO WAGES AND CONTRIBUTIONS
Previou sl y reported
Should have reported
Debit/(Credit)
A. TOTAL SUBJECT WAGES .................................................
B. UNEMPLOYM E NT INSURANCE ( UI) Taxa b l e Wages........
C.STATEDISABILITY INSURANCE (SDI) Taxable Wages....
D.EMPLOYER’S UI CONTRIBUTIONS (UI Rate 0.00% times B)...
E. EMPLOYMENT TRAINING TAX (ETT Rate 0.00% times B)...
F.
STATE DISABILITY INSURANCE* (SDI) Withheld (SDI Rate
0.00% timesC; compl eteBox 1below if credit on row F.)..
G
. PERSONAL INCOME TAX (PIT) Withheld (Complete
Box 2below if crediton line G.)...........................................
H.SUBTOTAL (Lines D, E, F, and G) . ..............................
I.Penalty (Refer t o instructio ns on DE 9ADJ-I) ................................................................................................
..................
J.Inte rest (R efer to i nstruc tions on DE 9ADJ-I) ................................................................................................
..................
K. Erroneous SDI Dedu c tions not refunded (See Box 1, NOTEbelow)................................................................
...............
L.Less contributions and withholdings paid for the quarter ................................................................................................
.
M. Totaltaxes due or o verpaid
(H2 + I + J + K) - L
................................................................................................
.............
*Includes Paid F amily Leave am ount.
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)?...............................................................YesNo
If yes, has this amount been refunded to employee(s)?................................................................................................. YesNo
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 deducti ons 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 Departm ent (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. I f yo u
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)?...................................................................YesNo
If yes, has this credit been refunded to employee(s)?....................................................................................................YesNo
2.Was the credit claimed in column 3 included on Forms W-2 issued to employee(s)?YesNo
Be sure to sign this declaration: Ideclare that the information hereinistrue and correct to the best of my knowledge and belief.
Signature Title Phone ()Date
(Owner, Accountant, Preparer, etc.)
SIGN AND MAIL T O: Employment Development Department / P.O. Box 989073 / West Sacramento, CA 95798-9073
STATUTE OF LIMITATIONS
A claim for refund or credit must
be filed within three years of the
last tim elyfiling date of th e q u arter
being adjusted.
Select:
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DE9ADJRev. 3 (7-13) (INTERNET) Page 2 of 2
QU ARTER L Y CO NT R IBU TIO N ANDWAGE ADJUSTMENT FORM
EMPLOYER ACCOUNT NO.
BUSINESS NAME
SECTION III: QUARTERLY W AGE AND WITHHOLDING ADJUSTMENTS
Enter amounts that should have been reported; if unchan ged, leave field blank. Correcting the Social Security Numbero r Name
requires two entries. See Instructions for Completing the Quarterly Contribution and Wage Adjustment Form(DE 9ADJ-I),
Section III, for additionalinformation and instructions.
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITIAL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
YEAR / QUARTER
SOCIAL SECURITY NUMB ER
EMPLOYEE NAME (FIRST, MIDDLE INITI AL, LAST)
TOTAL SUBJECT WAGES
PIT WAGES
PIT WITHHELD
