Annual Reconciliation Of Employee Earnings Tax - 2016

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CITY OF PHILADELPHIA
SOCIAL SECURITY NUMBER
No
ANNUAL RECONCILIATION OF 2016
Staples
0
2
1
6
EMPLOYEE EARNINGS TAX
DUE DATE APRIL 18, 2017
DO NOT FILE THIS RETURN if tax was 100% withheld on
Taxpayer Name and Address
all compensation by your employer.
If tax was
overwithheld by your employer, file the Employee Wage
Tax Refund Petition available at
in the forms & documents section.
Cancel this account by entering the termination date
AND file a CHANGE FORM.
m m d
d
y
y
y
y
YOU MUST USE A CHANGE FORM TO REPORT A CHANGE OF ADDRESS.
If this is an amended return place an "X" here:
IF YOU ARE NOT ELIGIBLE FOR PA 40 SCHEDULE SP, YOU ARE NOT ELIGIBLE FOR
INCOME-BASED TAXATION AND CANNOT USE LINES 5, 8, 11, OR 14.
,
,
.00
1. Gross Compensation received in 2016. Enclose 2016 W-2 form(s)......................................................1.
,
,
.00
2. Non-taxable gross compensation from Page 2, Line 5..........................................................................2.
,
,
.00
3. Gross taxable compensation (Line 1 minus Line 2)...............................................................................3.
4. Taxable Gross Compensation received by a resident of Philadelphia
,
,
.00
January 1, 2016 to June 30, 2016.......................................................................................................4.
5. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a resident of Philadelphia January 1, 2016 to June 30, 2016.......................................5.
,
,
.00
6. Tax Due (Line 4 times .039102 OR Line 5 times .034102 if claiming Income-based rate.)....................6.
7. Taxable Gross Compensation received by a resident of Philadelphia
,
,
.00
July 1, 2016 to December 31, 2016....................................................................................................7.
8. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a resident of Philadelphia July 1, 2016 to December 31, 2016.....................................8.
.00
,
,
9. Tax Due (Line 7 times .039004 OR Line 8 times .034004 if claiming Income-based rate).....................9.
10. Taxable Gross Compensation received by a nonresident of Philadelphia
,
,
.00
January 1, 2016 to June 30, 2016.....................................................................................................10.
11. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a nonresident of Philadelphia January 1, 2016 to June 30, 2016...............................11.
,
,
.00
12. Tax Due (Line 10 times .034828 OR Line 11 times .029828 if claiming Income-based rate)...............12.
13. Taxable Gross Compensation received by a nonresident of Philadelphia
,
,
.00
July 1, 2016 to December 31, 2016..................................................................................................13.
14. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a nonresident of Philadelphia July 1, 2016 to December 31, 2016............................14.
,
,
.00
15. Tax Due (Line 13 times .034741 OR Line 14 times .029741 if claiming Income-based rate)...............15.
,
,
.00
16. Total amount of Tax Due (Add Lines 6, 9, 12 and 15).........................................................................16.
17. Philadephia Wage Tax withheld by employer or credit for taxes paid to local jurisdictions
outside of PA. Attach W-2. See Instructions
,
,
.00
If Line 17 is greater than Line 16 file an Employee Wage Tax Petition for this amount...............17.
,
,
.00
18. Tax balance due. (Line 16 minus Line 17. Cannot be less than zero.)..............................................18.
,
,
19. Tax that you, not your employer, previously paid for 2016. (Not included on W-2 forms)................... 19.
.00
20. TAX DUE If Line 18 is greater than Line 19, enter here and in the Tax Due box
,
,
.00
of the Payment Coupon......................................................................................................................20.
21A. If Line 18 is less than Line 19, enter amount to be:
,
,
.00
REFUNDED. Do not file a separate Refund Petition. Enclose W-2 forms..................................21A.
,
,
.00
21B. Amount of overpayment to be APPLIED to the 2017 Earnings Tax Return......................................21B.
Under penalties of perjury, as set forth in 18 PA C.S. §§ 4902-4903 as amended, I swear that I have reviewed this return
and accompanying statements and schedules, and to the best of my knowledge and belief, they are true and complete.
Taxpayer Signature________________________________________ Date_______________________Phone #_________________________
Preparer Signature_________________________________________ Date_______________________Phone #_________________________
Page 1
0216 Generic 10-4-2016

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