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Delinquent Date. Reviewed by. Name DBA. 1. Complete the following section to amend individual wage items previously reported on Employer s Quarterly Contribution and Wage Report form NUCS-4072. If a reimbursable employer use this form to amend Form NUCS-4062. Employee Social Security No* Name of Employee Wages Previously Reported Correct Amount Wages Print or Type Dollars Cents TOTALS If more spaces are needed request Form NUCS-4500. Amended Difference ONLY Additional Amount Reduced Amount. NON ...

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