Form 1049W99701 Fillable Claim For Revision - Monthly/Quarterly Withholding
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(+ or ) (A) (B) (C) (D) *DF42414029999* 01/31/ 02/28/ 03/31/ 04/30/ 05/31/ 06/30/ 07/31/ 08/31/ 09/30/ 1 Enter Account Number 10/31/ 11/30/ 12/31/ 2 Business Name 3 Trade Name if Different from Above 4 Business Location Address 5 Mailing Address if Different 820 N French Street DELAWARE INCOME TAX WITHHELD amount withheld was corrected CLAIM FOR REVISION Department of Finance Division of Revenue FOR MONTHLY/QUARTERLY FILERS Enter the identification number under which tax returns have been filed You should be using a Federal Employer 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 Federal information is being corrected FORM 1049W99701 GENERAL INSTRUCTIONS Generally refunds of withholding taxes are not issued until the annual reconciliation is filed Most overpayments are applied by How many W 2s were filed with the original return? However if the overpayment is excessive use the Claim for Revision Form 1049W99701 to request consideration of a refund I declare under penalties as provided by law that the information on this application is true correct and complete Identification number If you are currently filing under a temporary identification number assigned by us enter that If filing corrected W 2s indicate the number of W 2s attached In the first column (Column A) Tax Period Ending please enter the tax year ending If amending more than one tax year a In the fourth column (Column D) Amount of Change please enter the difference between Columns B and C If the amount In the second column (Column B) Originally Reported please enter the amount of tax originally reported and paid for each In the third column (Column C) Corrected Amount please enter the corrected amount of tax withheld for each month is a negative amount please enclose the figure in brackets Line 1 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 MONTHLY AND/OR QUARTERLY WITHHOLDING TAX RETURNS number and provide us with your Federal Employer Identification number as soon as you get it of the overpayment during the calendar year You may also use this form if after filing your W 3 Reconciliation you find that an P O Box 8911 personal income tax return to claim the over withheld income taxes An employer is permitted to request a refund of Delaware Please indicate the number of corrected W 2s supplied Only provide copies of W 2s where the Delaware wages or Delaware Please submit any additional tax owed with the filing of this return required and deducted Delaware withholding taxes from its employees In such cases the employee must file a Delaware REV CODE 089 42 Revised 12/30/13 Revised 12/30/13 *DF42414019999* 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 separate Claim for Revision must be completed for each year SIGNATURE SPECIFIC LINE INSTRUCTIONS STATE OF DELAWARE State Zip Code Tax Period Ending Originally Reported Corrected Amount (For Office Use Only) (E)Amount of Change tax period Provide a breakdown for each month even if you filed your returns quarterly TELEPHONE NUMBER DATE The Claimant believes that this claim should be allowed for the following reasons: (Attach an additional sheet if needed ) the use of filing amended returns and applying the overpayment to offset an existing or future liability for the current year THIS FORM WILL BE COMPLETED BY EMPLOYERS NEEDING TO FILE AMENDED Total TOTAL AMOUNT DUE TOTAL AMOUNT OF OVERPAYMENT (Amount to be refunded see instructions ) Total Columns B C and D Use the Monthly or Quarterly Amended returns in your coupon booklet if only one return needs to be amended 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 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 Wilmington Delaware 19899 8911 FORM 1049W99701 withholding only when such amount was overpaid and not withheld from its employees