Revenue Operations (617) 626-5090 626-5091 Massachusetts Department of Workforce Development DISCREPANCY NOTICE Division of Unemployment Assistance Revenue Service, Fifth Floor 19 Staniford Street Boston, MA 02114-2589 QUARTER ENDING: EMPLOYER NO.: DUE: DATE: NAME/ADDRESS: THIS FORM IS TO BE USED ONLY FOR CORRECTING REPORT PREVIOUSLY SUBMITTED. SEE INSTRUCTIONS ON REVERSE SIDE. DUA USE ONLY A AS REPORTED B AS CORRECTED C INCREASE D DECREASE GROSS WAGES LESS: EXCESS WAGES TOTAL WAGES % CONTRIBUTION RATE % CONTRIBUTION DUE CONTRIBUTION PAID CONTRIBUTION INTEREST DUE CONTRIBUTION INTEREST PAID 1. ADDITIONAL CONTRIBUTION DUE 2. CONTRIBUTION INTEREST DUE 8. OVERPAID CONTRIBUTION 2A. PENALTY DUE 3. ADDITIONAL CONTRIBUTION AMOUNT DUE (ADD 1 + 2 + 2A) % WORKFORCE TRAINING FUND RATE % WORKFORCE TRAINING FUND DUE WORKFORCE TRAINING FUND PAID 4. ADDITIONAL WFT DUE WORKFORCE TRAINING FUND INTEREST DUE 5. WFT INTEREST DUE WORKFORCE TRAINING FUND INTEREST PAID 9. OVERPAID WFT 6. ADDITIONAL WFT AMOUNT DUE (ADD 4 + 5) PENALTY DUE PENALTY PAID NET TOTAL ➤ 7. AMOUNT DUE (ADD 3 + 6) 10. TOTAL OVERPAID ➤ (ADD 8 + 9) FOR EACH MONTH, ENTER THE NUMBER OF COVERED EMPLOYEES WHO WORKED DURING OR RECEIVED PAY FOR THE PAYROLL PERIOD WHICH INCLUDES THE 12 OF THE MONTH. IF NO EMPLOYMENT IN THE PAYROLL PERIOD, ENTER ZERO. ENTER EMPLOYEE COUNT 1ST MO. 2ND MO. 3RD MO. ➤ REASON FOR REFUND: CERTIFICATE (MUST BE EXECUTED) I certify the information in this report is true and correct to the best of my knowlege and belief; that the wages reported represent all wages paid during this quarter for employment covered by the Law; and that no part of the contribution reported was, or is to be deducted from workers’ wages. THIS STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. REPORT MUST BE SIGNED. Signed: Print Name: Title: Form 0735-NCR New 03-06 Date: Phone No.: Commonwealth of Massachusetts American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS TO EMPLOYER - PLEASE READ CAREFULLY   OVERPAID AMOUNTS WILL BE APPLIED TO PAST OR FUTURE DEBT. 0735-NCR Rev. 03-06 American LegalNet, Inc. www.FormsWorkflow.com