Form 1049l-9605 - Claim For Revision License Tax - 2012
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2012
STATE OF DELAWARE
Print Form
Department of Finance
CLAIM FOR REVISION
Division of Revenue
LICENSE TAX
820 N. French Street
REV CODE
-42
P.O. Box 2340
FORM 1049L-9605
Wilmington, Delaware 19899-2340
THIS FORM TO BE USED TO AMEND
GROSS RECEIPTS/EXCISE OR LICENSE TAX RETURNS
1.
Enter Account Number
_ _
_ _
2.
Business Code Group Description
3.
Business Name
4.
Trade Name if Different from Above
5.
Business Location Address
6.
Mailing Address if Different
City
State
Z ip Code
City
State
Zip Code
(A)
(B)
(C)
(D)
(E)
(F)
GROSS
GROSS
RECEIPTS
CORRECTED
REFUND OWED
TAX PERIOD
RECEIPTS
AMOUNT OF
CORRECTED
TAX AMOUNT
TAX OWED
ENDING
ORIGINALLY
TAX PAID
REPORTED
AMOUNT
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
$
7. TOTAL AMOUNT TO BE REFUNDED OR ADDITIONAL TAX OWED
SIGNATURE
PHONE NUMBER
DATE
I declare under penalties as provided by law that the information on this application is true, correct and complete.
Revised 11/21/11
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