State of Delaware Department of Labor 
                                        Division of Unemployment Insurance     
                                                    P. O. Box 9953  
                                        Wilmington, DE  19809 
                                                    (302) 761-8482 
 
                                        ADJUSTMENT APPLICATION 
 
 Employer Name                                          State Account Number:                           
 
 Dear Sir or Madam 
 
 We are amending Year-Quarter           for the above referenced company as indicated below 
 
                                                                                Total Wages Paid 
 1.  Social Security No           2.  Name of Employee  3.  As Reported               4. Should Be

 5.  Totals 
 6.  Difference (+or-) Column 4 Total - Column 3 Total 
 
                                        As Reported                Correctly Reported        Net Change
 7.   Total Gross Wages Paid in Quarter 
 8.   Wages in Excess of $18,500 
 9.   Taxable Wages 
 10. Contribution Due 
 11. Total Prior Payments 
 12. Credit 
 13. Balance Due - Check Attached 
 
 14. Reason for Adjustment: 
 
 All approved credits may be used on subsequent filings on line 6 of UC-8 for 
 
 Signature:                               Title:                                      Date:        
 
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