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03 03
DELAWARE DIVISION OF REVENUE
04 ANNUAL RECONCILIATION OF DE INCOME TAX WITHHELD FORM W3A 9801 *DF60116019999* 04
05 ACCOUNT NUMBER FOR OFFICE USE ONLY TAX PERIOD ENDING DUE ON OR BEFORE DF60116019999 05
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WR8
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10 Mail This Form With Remittance CHANGES MUST BE 1. Amount of Delaware Wages 10
11 Payable To: MADE ON THE REQUEST 11
STATE OF DELAWARE FOR CHANGE FORM.
12 DIVISION OF REVENUE CHECK THE BOX IF YOU 2. Number of Withholding Statements 12
ARE FILING A CHANGE
13 P.O. BOX 830 FORM. (Form W-2 and/or 1099 attached.) 13
WILMINGTON, DE 19899-0830
14 If you have questions, call (302) 577-8779 3. Total Delaware Income Tax WITHHELD 14
15 CHECK THE BOX IF W-2(S) AND/OR 1099s from Wages (as shown on attached forms.) 15
ARE BEING SUBMITTED ELECTRONICALLY.
16 4. Total Delaware Income Tax PAID during 16
the year from back of this form.
17 5. Difference between Line 3 and Line 4 17
18 Overpayment Balance Due 18
19 (Please remit Balance Due. Do not apply Refund Due to future payments. Refund will be issued from this document.) 19
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21 X TELEPHONE NUMBER DATE 21
AUTHORIZED SIGNATURE I declare under penalties of perjury that this is M M D D Y Y
22 a true, correct and complete return. EMAIL ADDRESS 22
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