CLGS-32-3 (1-13)
QUARTERLY ESTIMATED
Local Earned Income Tax Withholding
You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes. Contact your Tax Officer.
TRIM ALONG DOTTED LINE
1st QUARTER ESTIMATED Local Earned Income Tax
CLGS-32-3 (1-13)
If you moved, enter the effective date: ____/____/______
Check here if address change also applies to spouse
Make any corrections to NAME, STREET ADDRESS or
RESIDENT MUNICIPALITY and check here.
INCLUDE INFO IF NOT SHOWN.
1. Earned Income and/or net profits
.00
(must enter amount) January 1 thru March 31 . . .
.00
2. Tax Rate of _________ multiplied by line 1 . . . . . . . .
Resident PSD Code
Work Location PSD Code
.00
3. Employer Withheld (January 1 thru March 31 Only) . .
.00
4. TAX DUE: (line 2 minus line 3) . . . . . . . . . . . . . . . . . .
Resident Municipality:_______________________________________
5. Penalty and Interest: Line 4 multiplied by
.00
______ per month if paid after the due date . . . . . . .
If you have no earned income, state the reason: retired/homemaker/
.00
student/disabled/temporarily unemployed/minor (state age)/other
6. TOTAL PAYMENT DUE (add lines 4 & 5) . . . . . . . . .
(please specify)
❑
Payable to: ________________________________
Check here if ALL tax is withheld by employer(s).
Do not complete information requested on Lines 1 thru 6.
Social Security Number
DO NOT WRITE BELOW THIS LINE