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

                                        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 AMOUNT 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  09/18/15                                                   DF42214019999

        FORM1049L-9605                                                                           Page 2
                                 GENERAL INSTRUCTIONS

You may use this form to amend more than one taxable period in a single calendar year.
Youmustprovideadescriptionoftheerror(s)madeandprovidedocumentationtosubstantiatethechanges.Ifasufficient
explanation is not provided, and a refund is expected, your refund may be delayed until that information is provided.

Remitanyadditionaltaxowedwiththefilingofthisreturn.Refundsofoverpaymentswillbemadewithinsixtoeightweeks.
Ifyouhaveanyquestionsregardingrefunds,contacttheBusinessAuditBureauat(302)577-8268.

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. EntertheBusinessCodeGroupDescriptionfromyourcoupons.
Line 3. Enter the business name or individual name if a sole-proprietorship.
Line 4. Enterthetradenameofyourbusinessiftradingunderanameotherthanyourbusinessname.
Line 5. Enterthelocationaddressofyourbusiness;besuretoincludestreet,city,stateand nine-digitzipcode.
Line 6. Enter the mailing address of your business if different from the address on Line 5.

InColumnA, TaxPeriodEnding,pleaseenterthetaxyearending.Ifamendingmorethanonetaxyear,aseparateClaim
for Revision must be completed for each year.

InColumnB, GrossReceiptsOriginallyReported   ,pleaseentertheamountofgrossreceiptsoriginallyreportedandpaid
for each tax period. Provide a breakdown for each month even if you filed your returns quarterly.

In Column C, GrossReceipts CorrectedAmount   , 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.

InColumnE, CorrectedTaxAmount,pleaserecalculateyourtaxforeachperiodandenterthecorrecttaxamountowed.

InColumnF, RefundOwed/TaxOwed,pleaseenterthedifferencebetweentheamountoftaxoriginallypaidandthetax
owed.Iftheamountisanegativeamount(additionaltaxowed),enclosethefigureinbrackets().Pleaseremitanyamount
owedwith thisreturn.

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

        (Revised 09/18/15)                   *DF42214029999*
                                                                            DF42214029999