STATE OF DELAWARE
          Department of Finance              CLAIM FOR REVISION
              Division of Revenue            LICENSE TAX
              820 N. French Street
                P.O. Box 2340
        Wilmington, Delaware 19899-2340      FORM  1049L-9605                        Reset                             Print Form

                                         THIS FORM TO BE USED TO AMEND
                                GROSS RECEIPTS/EXCISE OR LICENSE TAX RETURNS

1. Enter Account Number                            -                  2. Calendar Year to be Adjusted

3. Business Code Group Description                    4. Choose One          Gross Receipts                         License

5. Business Name

6. Trade Name if Different from Above

7. Business Location Address                          8. Mailing Address if Different

   City                                                     City

    State   Zip Code                                         State  Zip Code

(A)                  (B)        GROSS    (C) GROSS    (D)                    (E)                                    (F)
    TAX PERIOD                  RECEIPTS     RECEIPTS       AMOUNT OF        CORRECTED                              REFUND OWED
      ENDING             ORIGINALLY      CORRECTED          TAX PAID         TAX AMOUNT                                TAX OWED
                                REPORTED     AMOUNT
        01/31/
        02/28/
        03/31/
        04/30/
        05/31/
        06/30/
        07/31/
        08/31/
        09/30/
        10/31/
        11/30/
        12/31/
 Total

8. TOTAL AMOUNT DUE                                                         $
        or
   TOTAL AMO UNT TO BE REFUNDED                                             $

          SIGNATURE                                   TITLE                                                         DATE
I declare under penalties as provided by law that the information on this application is true, correct and complete.

                                                                   *DF42214019999*
          Revised  0 /1 /3 2 20                                              DF42214019999

        FORM 1049L-9605                                                                                        Page 2
                                                    GENERAL INSTRUCTIONS

You may use this form   to amend more than one taxable              period  in     a single calendar year. 
You must provide   a description   of the error(s) made     and provide  documentation   to substantiate   the changes.     If a sufficient 
explanation   is not provided, and   a refund   is expected, your   refund may   be  delayed until that information is   provided.

Remit any additional tax owed   with   the filing   of this return. Refunds   of overpayments will be made within   six   to eight weeks. 
If you have any questions regarding refunds, contact the Business Audit Bureau   at (302) 577-           8780.

The Claimant believes that this claim should be allowed for         the following reasons:   (Attach an additional sheet  if   needed.)

                                                SPECIFIC LINE INSTRUCTIONS

Line 1. Enter the account number (from the coupon booklet) for which the correction is being made.
Line 2. Enter the Business Code Group Description from your coupons.
Line 3. Enter the business name or individual name if a sole-proprietorship.
Line 4. Enter the trade name of your business if trading under a name other than your business name.
Line 5. Enter the location address of your business; be sure to include street, city, state and nine-digit zip code.
Line 6. Enter the mailing address of your business if different from the address on Line 5.

In Column A, Tax Period Ending, please enter the tax year ending. If amending more than one tax year, a separate Claim
for Revision must be completed for each year.

In Column B, Gross Receipts Originally Reported             , please enter the amount of gross receipts originally reported and paid
for each tax period. Provide a breakdown for each month even if you filed your returns quarterly.

In Column C, Gross Receipts Corrected Amount                , please enter the amended amount of gross receipts for each month.

In Column D, Amount of Tax Paid,       please enter the amount of tax originally paid.

In Column E, Corrected Tax Amount, please recalculate your tax for each period and enter the correct tax amount owed.

In Column F, Refund Owed/Tax Owed, please enter the difference between the amount of tax originally paid and the tax
owed. If the amount is a negative amount (additional tax owed), enclose the figure in brackets ( ). Please remit any amount
owed with this return.

Total Columns B, C, D and E and enter the total from Column F on line 7.

         (Revised 0 /1 /3 2 20)                                                  *DF42214029999*
                                                                                             DF42214029999