Local Earned Income Tax Withholding Form Page 2
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PAGE
OF
EMPLOYER QUARTERLY RETURN for Local Earned Income Tax Withholding
Employer Business Location:
DCEDE12
Mailing Address:
Name
Address
Address
Year / Quarter
City
St
Zip Code
Account #
(12) EMPLOYEE'S NAME/ADDRESS
(14) AMOUNT OF EIT
(13) GROSS COMPENSATION
(15) RESIDENT
(11) EMPLOYEE'S
Check if making any corrections to EMPLOYEE’S
SOCIAL SECURITY NUMBER
PAID THIS QUARTER
PSD CODE
WITHHELD THIS QUARTER
Name/Address, SSN or Resident PSD
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(16 THIS PAGE TOTAL ................................................
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