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 $16,500                                                       
 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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