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)