DELAWARE DIVISION OF REVENUE                                                           FORM W3 9801                    *df60119019999*
ANNUAL RECONCILIATION OF DE INCOME TAX WITHHELD
                                                                                                                                          DF60119019999
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                           ACCOUNT NUMBER                                                               TAX PERIOD ENDING                 DUE ON OR BEFORE

                         0-000000000-000                                                                12-31-21                          02-01-22

     00890909000000000000012312102012200000000000000000000J

CHANGES MUST BE MADE ON THE REQUEST FOR CHANGE FORM.                                                  CHECK THE BOX IF W-2(S) AND/OR 1099s ARE BEING SUBMITTED 
CHECK THE BOX IF YOU ARE FILING A CHANGE FORM.                                                        ELECTRONICALLY.
Taxpayer Name:
                                                                                       1. Amount of Delaware Wages

                                                                                       2. Number of Withholding Statements
Taxpayer Address:                                                                                (Form W-2 and/or 1099 attached.)
                                                                                       3. Total Delaware Income Tax WITHHELD
                                                                                                 from Wages .(as shown on attached forms).
                                                                                       4. Total Delaware Income TaxPAID during the year.                       0.00

                                                                                       5. Difference between Line 3 and Line 4.                                0.00
Mail This Form With      Remittance  Payable To:                                       Enter the amount in 5a if there is any Balance Due 5a
STATE OF DELAWARE DIVISION OF REVENUE
P.O. BOX 2044                                                                                                                                                  0.00
                                                                                                                                          5b
WILMINGTON,  DE  19899-2044                                                            Enter the amount in 5b if there is any Overpayment
If you have questions, call (302) 577-8779

          (Please remit Balance Due. Do not apply Refund Due to future payments. Refund will be issued from this document.)

                                                                                       TELEPHONE NUMBER                                     DATE  M M D D Y Y
     X       AUTHORIZED SIGNATURE
I declare under penalties of perjury that this is a true, correct and complete return.
                                                                                       EMAIL ADDRESS

                                               WITHHOLDING WORKSHEET                                                                          Reset Worksheet

       TAX PAID                        TAX WITHHELD                                                                       TAX PAID               TAX WITHHELD

Jan.                                                                                                  July

Feb.                                                                                                  Aug.

Mar.                                                                                                  Sept.

Apr.                                                                                                  Oct.

May                                                                                                   Nov.

June                                                                                                  Dec.

TOTAL TAX PAID FOR THIS YEAR         $                                                 0.00                   TOTAL TAX WITHHELD            $                  0.00
(Enter amount on Line 4)                                                                                      (Should agree with Line 3)