
TEXAS WORKFORCE COMMISSION
PO BOX 149037
AUSTIN, TX 78714-9037
Form C-5 (0507)
- -
PURPOSE:
This report shall be used to correct
amounts of total and/or taxable wages
previously reported on Employer’s
Quarterly Report, Form C-3.
A separate report is required for
EACH calendar quarter adjusted.
For TWC Use Only:
2. Employer’s Name and Address:
Postmark Date
Amount Received
AE #
Inits.
Individuals may receive, review, and
correct information that TWC collects
about the individual by emailing to:
open.records@twc.state.tx.us
or writing to:
TWC Open Records
101 East 15
th
St Rm. 266
Austin, TX 78778-0001
3. Adjustment for the Quarter Ended:
2 0
Wages List Adjustment
Keyed by WRCE Keyed by B-27
Attached Not Attached Not Required
Please note: Lines 4 and 5 must be completed for columns A, B and C, even if no changes are made for one of the items.
(If no change for an item, please enter the same figure in columns A and B, and show $0.00 for column C.)
ITEMS
Amounts as Originally Reported on Form C-3 (or
previously adjusted on Form C-5) for this quarter:
Correct Amounts
Difference
Over Reported or Under
Reported
[Column A - Column B]
4. Total Wages Paid
$
5. Net Taxable Wages
$
6. Tax Contribution at % $ at %
$ at
$
7. Interest – If item 6C (Tax Contribution Difference) indicates additional tax due for this quarter, compute interest at 1.5%
of the additional tax due for each month after which the original payment became due.
$
8. Penalty – If the original Employers Quarterly Report (Form C-3) was submitted more than 15 days late for this quarter,
and the taxable wages have changed (as shown in item 5C), calculate the difference in penalty amount due. $
9. Total for this
Quarter
Underpayment: Attach remittance for the additional amount due.
Overpayment: Amount will be reflected on your next tax report and can be used to offset future
liabilities.
$
IMPORTANT: This section must be completed for each form submitted
Indicate reason for adjustment:
If amounts reported on Form C-4 for any individual employee(s) are affected by the
adjustment for this quarter, attach a Wages List Adjustment Schedule (Form C-7)
,
showing adjustment of the total wages reported for each affected employee.
Submitted Not Submitted
I certify that all information in this Adjustment Report is true and correct:
Signature: ___________________________________________________________________
(Owner, Officer, Partner, etc.)