Claim For Revision For Monthly/quarterly Filers Delaware Income Tax Withheld Form

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STATE OF DELAWARE
Department of Finance
CLAIM FOR REVISION
Division of Revenue
FOR MONTHLY/QUARTERLY FILERS
820 N. French Street
089
DELAWARE INCOME TAX WITHHELD
REV CODE
-42
P.O. Box 8911
FORM 1049W99701
Wilmington, Delaware 19899-8911
THIS FORM WILL BE COMPLETED BY EMPLOYERS NEEDING TO FILE AMENDED
MONTHLY AND/OR QUARTERLY WITHHOLDING TAX RETURNS
1.
Enter Account Number
_ _
_ _
2.
Business Name
3.
Trade Name if Different from Above
4.
Business Location Address
6.
Mailing Address if Different
City
State
Zip Code
City
State
Zip Code
If filing corrected W-2s, indicate the number of W-2s attached.
How many W-2s were filed with the original return?
Amount of Change
(For Office Use Only) (E)
Tax Period Ending
Originally Reported
Corrected Amount
(A)
(B)
(C)
(D)
(+ or -)
01/31/
02/28/
03/31/
04/30/
05/31/
06/30/
07/31/
08/31/
09/30/
10/31/
11/30/
12/31/
Total
$
TOTAL AMOUNT DUE
or
$
TOTAL AMOUNT OF OVERPAYMENT (Amount to be refunded, see instructions.)
SIGNATURE
TELEPHONE NUMBER
DATE
I declare under penalties as provided by law that the information on this application is true, correct and complete.

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