TEXAS WORKFORCE COMMISSION
PO BOX 149037 33333
AUSTIN, TX 78714-9037
ADJUSTMENT REPORT
1. TWC Account number:
PURPOSE: For TWC Use Only:
- - This report shall be used to correct
amounts of total and/or taxable wages Result of Audit? Yes / No
2. Employer’s Name and Address: previously reported on Employer’s
Quarterly Report, Form C-3. Column A Verified? Yes / No
A separate report is required for
EACH calendar quarter adjusted.
Individuals may receive, review, and Mo. Day Year
correct information that TWC collects Postmark Date
about the individual by emailing to: Dollars Cents
open.records@twc.state.tx.us
or writing to:
Amount Received AE # Inits.
101 East 15 St Rm. 266
3. Adjustment for the Quarter Ended: TWC Open Recordsth Wages List Adjustment
Austin, TX 78778-0001 Keyed by WRCE Keyed by B-27
2 0
Month Day Year Attached Not Attached Not Required
Please note: Lines 4 and 5 must be completed for columns A, B and C, even if no changes are made for one of the items.
(If no change for an item, please enter the same figure in columns A and B, and show $0.00 for column C.)
A B C
Amounts as Originally Reported on Form C-3 (or Difference
ITEMS previously adjusted on Form C-5) for this quarter: Correct Amounts Over Reported or Under
Reported
Dollars . Cents __ Dollars . Cents __ [Column A - Column B]
4. Total Wages Paid $
5. Net Taxable Wages $
6. Tax Contribution at % $ at % $ at % $
7. Interest – If item 6C (Tax Contribution Difference) indicates additional tax due for this quarter, compute interest at 1.5%
$
of the additional tax due for each month after which the original payment became due.
8. Penalty – If the original Employers Quarterly Report (Form C-3) was submitted more than 15 days late for this quarter,
and the taxable wages have changed (as shown in item 5C), calculate the difference in penalty amount due. $
Underpayment: Attach remittance for the additional amount due.
9. Total for this
Overpayment: Amount will be reflected on your next tax report and can be used to offset future $
Quarter liabilities.
IMPORTANT: This section must be completed for each form submitted
Indicate reason for adjustment:
If amounts reported on Form C-4 for any individual employee(s) are affected by the
Form C-7:
adjustment for this quarter, attach a Wages List Adjustment Schedule (Form C-7),
showing adjustment of the total wages reported for each affected employee. Submitted Not Submitted
I certify that all information in this Adjustment Report is true and correct:
Signature: ___________________________________________________________________ Phone: ( )
Print Name: Title: Date:
(Owner, Officer, Partner, etc.)
Form C-5 (0507)