Employer'S Quarterly Earned Income Tax Return

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EMPLOYER’S QUARTERLY EARNED INCOME TAX RETURN
1. WAGES SUBJECT TO EARNED INCOME TAX
(ITEM # 15 TOTAL ALL PAGES)
$
2. EARNED INCOME TAX WITHHELD (TOTAL ITEM 16)
MAKE CHECKS
PAYABLE TO
3. CREDIT OR ADJUSTMENT (ATTACH EXPLANATION)
4. PENALTY AND INTEREST (1% PER MONTH)
$
5. BALANCE DUE WITH THIS RETURN
6. IF THERE HAS BEEN A CHANGE OF OWNERSHIP OR OTHER
7. DO YOU EXPECT TO PAY
TRANSFER OF BUSINESS DURING THE QUARTER, ATTACH
TAXABLE WAGES NEXT
EXPLANATION AND GIVE THE NAME OF THE PRESENT OWNER
QTR.
AND DATE THE CHANGE TOOK PLACE.
YES
NO
CHANGE
NO CHANGE
NO.
8. TOTAL NUMBER OF
9. QUARTER ENDED:
10.
(2) JUN. 30,
EMPLOYEES
(1) MAR. 31, ______
(2) SEP. 30, ______
PAGE NO. ______
LISTED
(3) SEP. 30,
(3) JUN. 30, ______
(4) DEC. 31, ______
OF ____________
I DECLARE UNDER THE PENALTIES BY LAW THAT THIS RETURN IS A COMPLETE STATEMENT AND TO
THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE AND COMPLETE RETURN
SIGNED
TITLE
DATE
D.W.
EMPLOYER
SEQ.
TAX DISTR.
OFF
EMPLOYERS NAME, ADDRESS & PRINCIPAL PLACE OF BUSINESS
NAME OF EMPLOYEE
CITY, BOROUGH, OR TOWNSHIP OF
EMPLOYEES SOCIAL SECU-
TAXABLE GROSS EARNINGS PAID TO
AMOUNT OF TAX
EMPLOYEE’S RESIDENCE
RITY NUMBER
THE EMPLOYEE IN THIS QUARTER
WITHHELD
(11)
(12)
(13)
(14)
(15)
(16)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
PAY THIS AMT.
Payment due by
TOTAL EARNINGS REPORTED IN COLUMN 15 ON THIS PAGE
last of month
TOTAL TAX WITHHELD IN COLUMN 16 ON THIS PAGE
following close
of quarter.

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