Form Emst 4 - Emergency And Municipal Services Tax Employer'S Return

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1. Total number of employees reported herewith
1
FORM EMST 4
EMERGENCY AND MUNICIPAL
2. Gross amount of tax-Line 1 X
2
SERVICES TAX
EMPLOYER’S RETURN
3.
3
PAYABLE & MAIL TO:
4. Net amount due - Enclosed (Line 2 minus Line 3)
4
5. Penalty
5
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION
6. Interest (
1
/
% per month)
6
2
HEREIN CONTAINED IS TRUE AND CORRECT.
AUTHORIZED
7. Total - Including any penalty and interest due
7
SIGNATURE
These funds were transmitted via ACH on ____________________(Date)
DATE FILED
FOR PERIOD
Name and Address
Account No.
DUE ON OR BEFORE
FOR INQUIRIES AND ADDITIONAL FORMS CONTACT:
– Instructions Reverse Side Pt. 2

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