Form Ct-1 X - Adjusted Employer'S Annual Railroad Retirement Tax Return Or Claim For Refund Page 3

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Name

Employer identification number (EIN)

Calendar Year (YYYY)

Part 4: Explain your corrections for this year.

19. Check here if any corrections you entered on a line include both underreported and overreported amounts.

Explain both your underreported and overreported amounts on line 21.

20. Check here if any corrections involve reclassified workers. Explain on line 21.

21. You must give us a detailed explanation for how you determined your corrections. See the instructions.

Part 5: Sign here. You must complete all three pages of this form and sign it.

Under penalties of perjury, I declare that I have filed an original Form CT-1 and that I have examined this adjusted return or claim and any schedules or

statements that are attached, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer)

is based on all information of which preparer has any knowledge.

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title here

Date

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Check if you are self-employed .