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GENERAL INSTRUCTIONS

FORM 1049W99701

Section 537 of Title 30 of the Delaware Code provides that no credit or refund will be made to any employer if the employer was

required and deducted Delaware withholding taxes from its employees. In such cases the employee must file a Delaware

personal income tax return to claim the over withheld income taxes. An employer is permitted to request a refund of Delaware

withholding only when such amount was overpaid and not withheld from its employees.

Generally, refunds of withholding taxes are not issued until the annual reconciliation is filed. Most overpayments are applied by

the use of filing amended returns and applying the overpayment to offset an existing or future liability for the current year.

However, if the overpayment is excessive, use the Claim for Revision Form 1049W99701 to request consideration of a refund

of the overpayment during the calendar year. You may also use this form if after filing your W-3 Reconciliation you find that an

error was made on am employee’s W-2 or on the amounts reported as being paid or other error made on the original filing of the

W-3. Be sure to complete all information requested on this form. Do not send duplicate copies of all your W-2s; send only the

W-2s on which a correction was made to the Delaware information. You do not need to file a corrected W-2 with us if only the

Federal information is being corrected.

Use the Monthly or Quarterly Amended returns in your coupon booklet if only one return needs to be amended.

The Claimant believes that this claim should be allowed for the following reasons: (Attach an additional sheet if needed.)

SPECIFIC LINE INSTRUCTIONS

Line 1.

Enter the identification number under which tax returns have been filed. You should be using a Federal Employer

Identification number. If you are currently filing under a temporary identification number assigned by us, enter that

number and provide us with your Federal Employer Identification number as soon as you get it.

Line 2.

Enter the business name.

Line 3.

Enter the trade name of your business if trading under a name other than your business name.

Line 4.

Enter the location address of your business; be sure to include street, city, state and nine-digit zip code.

Line 5.

Enter the mailing address of your business if different from the address on Line 4.

Please indicate the number of corrected W-2s supplied. Only provide copies of W-2s where the Delaware wages or Delaware

amount withheld was corrected.

In the first column, (Column A), Tax Period Ending, please enter the tax year ending. If amending more than one tax year, a

separate Claim for Revision must be completed for each year.

In the second column, (Column B), Originally Reported, please enter the amount of tax originally reported and paid for each

tax period. Provide a breakdown for each month even if you filed your returns quarterly.

In the third column, (Column C), Corrected Amount, please enter the corrected amount of tax withheld for each month.

In the fourth column, (Column D), Amount of Change, please enter the difference between Columns B and C. If the amount

is a negative amount, please enclose the figure in brackets.

Please submit any additional tax owed with the filing of this return.

Total Columns B, C and D.

*DF42414029999*

Revised 12/30/13

Form 1049w99701 - Claim For Revision For Monthly/quarterly Filers Delaware Income Tax Withheld Page 2