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TEXAS WORKFORCE COMMISSION
Austin, TX 78714-9037
Wage List Adjustment Schedule Page No. Of
(To Correct Total Wages Previously Filed on Form C-4)
Account Number: Qtr./Yr.
Employer's Name and Address: See Reverse Side For Instructions
If the Social Security number, name or wages of one or
more employees were omitted from or erroneously reported
on a Wages List, each such error should be corrected on
this form. List only the data for which corrections are
required.
Reason For Adjustment: For TWC Use Only
Audited by Prepared By
AE Number AE Number
Important (If this adjustment affects total or taxable wages reported on Form C-3, Employer's Quarterly Report, you
must complete Form C-5, Adjustment Report.) C-5 Attached
(1) (2) (3) (4)
Employee's Employee's Name Total Wages
st nd
Social S ecurity 1 2
Account Number Init. Init. Last As Reported Corrected
Totals
Completed forms, inquiries, or corrections to the individual information contained in this form shall be sent to the TWC Tax Department, PO Box
149037, Austin, Texas 78714-9037, (512) 463-2699. Individuals may receive and review information that TWC collects about the individual by
emailing to open.records@twc.state.tx.us or writing to TWC Open Records, 101 E. 15th St., Rm. 266, Austin, TX 78778-0001.
I certify all information contained in this adjustment is true and correct.
Signed Title Date 20
(Signature and Title-Owner, Partner, President, Etc.)
C-7 (0907) Inv. No. 518950
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