Adjustment Application - Delaware Department Of Labor
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1State of Delaware
Department of Labor
Division of Unemployment Insuranc
P. O. Box 9953
Wilmington, DE 19809
(302) 761-8482
ADJUSTMENT APPLICATION
Employer Name:
______________________________
_________________
State Account Number:
Dear Sir or Madam:
We are amending Year-Quarter_______for the above referenced company as indicated below
Total Wages Paid
1. Social Security No
2. Name of Employee
3. As Reported
4. Should Be
5. Totals
6. Difference (+or-) Column 4 Total - Column 3 Total
As Reported
Correctly Reported
Net Change
7. Total Gross Wages Paid in Quarter
8. Wages in Excess of $8500
9. Taxable Wages
10. Contribution Due
11. Total Prior Payments
12. Credit
13. Balance Due - Check Attached
14. Reason for Adjustment:
All approved credits may be used on subsequent filings on line 6 of UC-8 form
Signature: ___________________________ Title: _________________________
Date:___________
g:\acctmgmt\forms\adjapp
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