TEXAS WORKFORCE COMMISSION 
                                                     Austin, TX 78714-9037 
                                                    Wage List Adjustment Schedule                  Page No.                               Of            

                                  (To Correct Total Wages Previously Filed on Form C-4) 
 Account Number:                                                                                   Qtr./Yr.             

 Employer's Name and Address:                                             See Reverse Side For Instructions 
                                                                If the Social Security number, name or wages of one or 
                                                                more employees were omitted from or erroneously reported 
                                                                on a Wages List, each such error should be corrected on 
                                                                this form.  List only the data for which corrections are 
                                                                required. 

 Reason For Adjustment:                                                                                       For TWC Use Only 
                                                                                                   Audited by              Prepared By 
                                                                                                   AE Number              AE Number  
                                                                                                
 Important (If this adjustment affects total or taxable wages reported on Form C-3, Employer's Quarterly Report, you 
 must complete Form C-5, Adjustment Report.)                 C-5 Attached                                                                 
                       
                       (1)                                (2)                                  (3)                               (4) 
                  Employee's                     Employee's Name                                   Total Wages 
                                              st     nd
                 Social S ecurity         1      2                                                                                
                Account Number            Init.  Init.           Last              As Reported                              Corrected 
                                                                                                                                                     
                                                                 Totals                                                                              
                                                           
 Completed forms, inquiries, or corrections to the individual information contained in this form shall be sent to the TWC Tax Department, PO Box 
 149037, Austin, Texas 78714-9037, (512) 463-2699. Individuals may receive and review information that TWC collects about the individual by 
 emailing to open.records@twc.state.tx.us or writing to TWC Open Records, 101 E. 15th St., Rm. 266, Austin, TX 78778-0001.  

                                  I certify all information contained in this adjustment is true and correct. 
 Signed                                        Title                       Date                                               20                  
                                         (Signature and Title-Owner, Partner, President, Etc.) 
 
C-7 (0907) Inv. No. 518950 

         A Separate Form Must Be Filed For Each Quarter Being Corrected. 
                     List Only The Data For Which Corrections Are Required 
                                                   
                     Examples To Correct Data Previously Reported or Omitted 
                                                    
     (1)                                          (2)                       (3)             (4) 
     Employee's                         Employee's Name                         Total Wages 
     Social Security      1st              2nd                                               
     Account Number       Init.            Init.   Last         As Reported                Corrected 
                                                                                             
     The following example illustrates the proper method to report either omitted Social 
     Security Account Number(s) or Wage Amount(s).  The Total Wages, As Reported, 
     Column (3) will be -0- as no wages were credited to employee's earning records due to 
     the omitted Social Security Account Number or wage amount. 
 
 123 45              6789                J. A. DOE                          -0-            1,000.00 
 
     The following example illustrates the proper method to correct the amount of wages 
     previously reported for J. A. Doe. 
 
 123 45              6789                J. A. DOE              1,000.00                   1,200.00 
 
     The following example illustrates the proper method to correct wages erroneously 
     reported for J. B. Doe instead of J. A. Doe. 
 
 123 45              6789                J. B. DOE              1,000.00                    -0- 
 123 45              6789                J. A. DOE                          -0-            1,000.00 
 
     The following example illustrates the proper method to correct the reporting of an 
     erroneous Social Security Account Number. 
 
 123 54              6789                J. A. DOE              1,000.00                    -0- 
 123 45              6789                J. A. DOE                          -0-            1,000.00