&'(' 

                                	)""  
                                               	
	#

                         !  # 	
                         ! # 	  	
                         ! %	

      5"("$9;"",)*;$                           @
7                                                                                                         +
           3/::39,> 

                                                                                       "
           5                                                                            $
                                                                                                            (

7D')(/ 

           45937,5.7

 /

4.253C8:7.24:E7:937 E<74.;2<72287 ;<582F7 7.7:735G7

           .;&/*D                                             ;(#
           7                                                                                             ;D
      4238:.5: 7=#(@=375= 7 C
;                                                                                                         ;*
                                              7	                                             ;&
7                                                                           ;'
                           4                                                                              ;@
           7	 !;$;"%                                                       ;+

7;$                                                                  ;"
                               */;$/ 
79,> !,)*5% #!0%,) ;$
                           ($
-/                                                                                            ;(

                               ,

4567,85397: 7,;<2.7).37 3-24523235=7.2:	 
 
0 
$#,-.'#"/ 

STATE OF DELAWARE UNEMPLOYMENT INSURANCE
Use this form to report changes in status or corrections to pre-printed information

DELAWARE DEPARTMENT OF LABOR
DIVISION OF UNEMPLOYMENT INSURANCE
P.O. BOX 41785
PHILADELPHIA, PA  19101-1785

 !"#$%$!!" &%!"&!'!
$"

$"&!%#$!!" &%!"&!'!
$"

('%&!%%)$!&*++"&
$"

('%&!%%%!
$"

$,$!)"&!

,!!'-./

0$&&!)%%

 .2 
,$!)&!#!%,&&!"%"
	$%3$&!

 +",$ %,#!1 &%&!"1$%&!""!'-,

X
2&)!$"'+#!' $'",&*%!"$"& &" $"

CHANGE REPORT

 !"#

$$% &'(% 

% ( + ( 
	
MAIL PAYMENT TO:
DELAWARE DEPARTMENT OF LABOR
DIVISION OF UNEMPLOYMENT INSURANCE
P.O. BOX 41785
PHILADELPHIA, PA  19101-1785

PAYMENT COUPON

STATE OF DELAWARE UNEMPLOYMENT INSURANCE

#$%&'(#&)*!+%,
-#.%#
-'%
	#)#./
 .1.%#
9 	#.5'%5:#$%%5#'-0#28##)3;#735 97%'%5 <')'%5  )'%5
3;#))-&'(##&8#)$.42%5#$.4//$#&)35&5
&'/-)#7%5#9<%52%5#'%5
< 778##)3.(#7$.&)%5&7=-.%#*'%#%%./2:/&'#  ,

  1#773.(#7*?.(#7&'/-)#)&'/&'#<%5.%#1##)@9:A.''-.//4$##$/4##,
B  .1.0/#?.(#7*&'#</#77/&'# ,
A  .1)-#*-/%&$/4/&'#B04,
 $$8#)#)&%*##&'7%-%&'7,
C #%%.1)-#*&'#A/#77/&'#,

D #'./%4*@9C<A2/.%##$%&'(,
  	 9 .4#'%)-#* %./2/&'#7C:.')D,

$.4//#$%7.#%-#.')#% .;#5#;$.4.0/#%E
#/.3.#'#$/4#'%
$#'7.%&'	-')*	,
	 X &('.%-#23'#)-/4.-%5&6#)#$#7#'%.%&8#
?&%#.-'%'-0#'
5#;.')#%-'3&%5
 &%/# .%# .4#'%-$'

QUARTERLY TAX REPORT
!!

STATE OF DELAWARE UNEMPLOYMENT INSURANCE

('(6'7&') 7','8 +' 9:(;'))+*(7(
)+'')'*'''
Employee Social Security Number Employee Name (First Initial, Middle Initial and Last Name) Gross Covered Wages
-
.
/
0
%
#
1
"

2
-$
--
-.
-/
-0
-%
-#
-1
') +)'()( -"
 -2

.$
'7(6':'('*')&)('6',('
.-
..
./
.0
.%
.#
.1
."
.2
/$
/- )34
/. )5  	
// &)(),
 !"#$!$#$$$"$% (()*')+*'()
QUARTERLY PAYROLL REPORT )(,' (' )(*
&'  (