Form C-5 - Adjustment Report
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1TEXAS WORKFORCE COMMISSION
33333
PO BOX 149037
AUSTIN, TX 78714-9037
ADJUSTMENT REPORT
1. TWC Account number:
PURPOSE:
For TWC Use Only:
-
-
This report shall be used to correct
amounts of total and/or taxable wages
Result of Audit?
Yes /
No
2. Employer’s Name and Address:
previously reported on Employer’s
Column A Verified?
Yes /
No
Quarterly Report, Form C-3.
A separate report is required for
EACH calendar quarter adjusted.
Mo.
Day
Year
Individuals may receive, review, and
Postmark Date
correct information that TWC collects
about the individual by emailing to:
Dollars
Cents
open.records@twc.state.tx.us
or writing to:
Amount Received
AE #
Inits.
TWC Open Records
3. Adjustment for the Quarter Ended:
Wages List Adjustment
th
101 East 15
St Rm. 266
Austin, TX 78778-0001
Keyed by WRCE
Keyed by B-27
2 0
Attached
Not Attached
Not Required
Month
Day
Year
Please note: Lines 4 and 5 must be completed for columns A, B and C, even if no changes are made for one of the items.
(If no change for an item, please enter the same figure in columns A and B, and show $0.00 for column C.)
A
B
C
Amounts as Originally Reported on Form C-3 (or
Difference
Correct Amounts
ITEMS
previously adjusted on Form C-5) for this quarter:
Over Reported or Under
Reported
.
.
[Column A - Column B]
Dollars
Cents__
Dollars
Cents__
4. Total Wages Paid
$
5. Net Taxable Wages
$
6. Tax Contribution
at
% $
at
% $
at
% $
7. Interest – If item 6C (Tax Contribution Difference) indicates additional tax due for this quarter, compute interest at 1.5%
$
of the additional tax due for each month after which the original payment became due.
8. Penalty – If the original Employers Quarterly Report (Form C-3) was submitted more than 15 days late for this quarter,
and the taxable wages have changed (as shown in item 5C), calculate the difference in penalty amount due.
$
Please see instruction sheet for details.
Underpayment: Attach remittance for the additional amount due.
9. Total for this
Overpayment: Amount will be reflected on your next tax report and can be used to offset future
$
Quarter
liabilities.
IMPORTANT: This section must be completed for each form submitted
:
Indicate reason for adjustment
If amounts reported on Form C-4 for any individual employee(s) are affected by the
Form C-7:
adjustment for this quarter, attach a Wages List Adjustment Schedule (Form C-7),
Submitted
Not Submitted
showing adjustment of the total wages reported for each affected employee.
I certify that all information in this Adjustment Report is true and correct:
Signature: ___________________________________________________________________
Phone: (
)
Print Name:
Title:
Date:
(Owner, Officer, Partner, etc.)
Form C-5 (0507)
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