Electronic Form Processing - DO NOT STAPLE OR SUBMIT COPIES - Use Black Ink DOL - 3C (R-8/05)

GEORGIA
DEPARTMENT OF LABOR
REPORT TO ADD NEW WAGES *00301*
AND/OR CORRECT REPORTED WAGES
00301

Mail Completed Form To: For Department Use Only 409

GDOL - EMPLOYER ACCOUNTS, Room 768
148 Andrew Young International Blvd., N.E., Date Received Supplemental
Atlanta, GA 30303-1751
Phone: (404) 232-3245
M M / D D / Y Y Y Y Correction

SECTION A
Employer Name, Address and E-mail Address
DOL Account Number Total Tax Rate
- .
Qtr / Yr End Date
Q / Y Y Y Y M M / D D / Y Y Y Y
Federal I.D. Number

SECTION B
DOL-4, Item 2 DOL-4, Item 3 DOL-4, Item 4 PLEASE INCLUDE YOUR DOL
Total wages Non-Taxable Wages Taxable Wages ACCOUNT NUMBER ON ALL CHECKS
AND CORRESPONDENCE

SECTION C
Individual Quarterly Wages Reported And Corrected
Total Wages Taxable Wages
Pages

Social Security No. Employee Name

Reported Corrected Reported Corrected

12345678901234567890123456789012123
12345678901234567890123456789012123
12345678901234567890123456789012123
12345678901234567890123456789012123 Totals
SECTION D
Increase Decrease

1. Total GROSS WAGE Corrections , , . , , .

2. Non-Taxable Wage Corrections , , . , , .
3. Taxable Wage Corrections , , . , , .
4. Contribution Tax on Corrections

5. Admin Assessment on Corrections 1234567890123456789012345678901212345678

1234567890123456789012345678901212345678
6. Interest on Lines 4 & 5
1234567890123456789012345678901212345678
1234567890123456789012345678901212345678
7. Additional Tax or Credit Due
SECTION E
Corrected Summary of Total Wages Corrected Summary of Taxable Wages

Explanation

Submitted By _______________________________ Title ________________________ Date ____________ ( )

Phone _______________________

Page of
 INSTRUCTIONS FOR COMPLETING FORM DOL-3C

“REPORT TO ADD NEW WAGES AND/OR CORRECT REPORTED WAGES”

The form is designed to: (1) correct previously reported wages and/or (2) report individuals that were omitted from the
original Employer’s Quarterly Tax and Wage Report, Form DOL-4. Complete one or more of these forms separately for
each quarterly report that is to be corrected.

SECTION A
Enter the DOL Account Number. Enter the Total Tax Rate, (Contribution plus Administrative Assessment). Enter the quarter
and 4-digit year. Enter the quarter ending date. Enter the Federal I.D. Number. Enter Employer Name, Address and E-mail
Address.

SECTION B
Enter the amounts as originally reported on lines 2, 3 & 4 of the Employer’s Quarterly Tax and Wage Report, Form DOL-4
being corrected.

SECTION C
Enter the Social Security Numbers and Names of the employees omitted or incorrectly reported on the original report. Enter
the page number on which the employees were originally reported. In the spaces provided, enter the amount of total wages
reported for the employee, the corrected amount of total wages; the taxable wages reported (amount included in Line 4 of the
Quarterly Tax and Wage Report), and the corrected amount of taxable wages.

Total and taxable wages as reported and as corrected should be totaled, as the last item in Section C. Page totals should be
entered on each page if more that one form is submitted for a quarter. The final total should be entered on the last page.

SECTION D
Line 1: Enter the difference between the Total Wages Reported and the Total Corrected Wages from Section C as either an
increase or decrease, if applicable.
Line 2: Enter the difference between the Total Corrected Wages and the Taxable Corrected Wages from Section C as either an
increase or decrease.
Line 3: Enter the difference between the Total Taxable Wages Reported and the Total Corrected Taxable Wages amount from
section C as either an increase or decrease.
Line 4: Multiply the Taxable Wages, Line 3 by the contributory tax rate for that quarter.
Line 5: Multiply the Taxable Wages, Line 3 by the administrative assessment tax rate for that quarter.
Line 6: Interest is computed on the tax due (Line 4 + Line 5) from the due date until paid at the rate of one and one-half
percent (1-1/2%) per month or fraction of a month. Interest is not applicable on a tax decrease.
Line 7: Enter total of Line 4 through 6. If the total reflects an increase in tax due, make check payable to Georgia Department
of Labor. Please include your Georgia DOL Account Number on your check. A decrease may result in a credit to your
account.

SECTION E
To adjust total wages, the amount of increase should be added to the amount entered in Item 2 in Section B or the amount of
decrease should be subtracted from Item 2 in Section B. The result of the addition or subtraction should be entered as Cor-
rected Summary of Total Wages.

To adjust taxable wages, the amount of increase should be added to the amount entered in Item 4 in Section B or the amount of
decrease should be subtracted from Item 4 in Section B. The result of the addition or subtraction should be entered as Cor-
rected Summary of Taxable Wages.

Enter your explanation of the adjustment in the space provided.

Enter your Name on the “Submitted By” line, Title, Date, and Telephone Number and return as indicated on the front of the
form.