Form 1049w99701 - Claim For Revision For Monthly/quarterly Filers Delaware Income Tax Withheld

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STATE OF DELAWARE
CLAIM FOR REVISION
Department of Finance
FOR MONTHLY/QUARTERLY FILERS
Division of Revenue
820 N. French Street
DELAWARE INCOME TAX WITHHELD
P.O. Box 8911
089
REV CODE
- 42
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
5. Mailing Address if Different
4.
Business Location Address
City
City
State
Zip Code
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
Tax Period Ending
Originally Reported
Corrected Amount
(For Office Use Only) (E)
(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.
*DF42414019999*
Revised 12/30/13

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