Earned Income Tax Quarterly Return Form - Mt. Lebanon, Pa. And Mt. Lebanon School District
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1MT. LEBANON, PA. AND MT. LEBANON SCHOOL DISTRICT
ACCOUNT #
EARNED INCOME TAX QUARTERLY RETURN
TAX YEAR:
QTR:
1 ACTUAL WAGES AND/OR ESTIMATED NET PROFITS
1 ______________________
2 TAX DUE AT 1.3% OF LINE 1
2 ______________________
3 CREDIT FROM PREVIOUS YEARS AND/OR TAX WITHHELD
3 ______________________
4 TAX DUE WITH THIS RETURN
4 ______________________
5 PENALTY/INTEREST DUE (1% PER MONTH AFTER DUE DATE)
5 ______________________
6 TOTAL AMOUNT DUE WITH THIS RETURN
6 ______________________
EMPLOYER:
____________________________
SS#:
DUE DATE:
MAKE CHECKS PAYABLE TO:
MT. LEBANON, PA.
RETURN THIS PORTION TO THE MT. LEBANON TREASURER’S OFFICE
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ACCOUNT #
NAME:
TAX YEAR:
QTR:
1 ACTUAL WAGES AND/OR ESTIMATED NET PROFITS
1 ______________________
2 TAX DUE AT 1.3% OF LINE 1
2 ______________________
3 CREDIT FROM PREVIOUS YEARS AND/OR TAX WITHHELD
3 ______________________
4 TAX DUE WITH THIS RETURN
4 ______________________
5 PENALTY/INTEREST DUE (1% PER MONTH AFTER DUE DATE)
5 ______________________
6 TOTAL AMOUNT DUE WITH THIS RETURN
6 ______________________
IMPORTANT NOTICE
FROM: John C. Ferguson, Jr., Treasurer
Mt. Lebanon Treasurer’s Office
710 Washington Road
Pittsburgh, Pa. 15228
412-343-3405
THIS IS YOUR QUARTERLY EARNED INCOME TAX RETURN, YOU MUST, BY LAW,
COMPLETE AND RETURN THIS FORM
SPECIAL INSTRUCTIONS
1. REPORT AND MAKE PAYMENT At 1.3% of this year’s first quarter actual and/or estimated earnings.
2. WRITE your employer’s name and “WITHHELD” if your employer pays your tax.
3. CORRECT the information on the front of the return. Please print address corrections on reverse side
of the
Tax Office Copy.
4. RETAIN the “Taxpayer Receipt” for your records.
THE MT. LEBANON TAX OFFICE PROVIDES SERVICES ON AN EQUAL OPPORTUNITY BASIS
ACT 50 COMPLIANCE NOTICE
You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement,
refund and collection of local taxes by calling Mt. Lebanon Tax Office at 412-343-3405 during the hours of 8:30
A.m. to 5 p.m., Monday through Friday (closed on holidays).
TAX PAYMENT OPTION
You may make Earned Income Tax payment via credit card through OFFICIAL PAYMENTS CORP.
OFFICIAL PAYMENTS charges a fee for this service.
Access their website
OR call then at 1-800-487-4567 Option 4 for instructions.
DUPLICATE TAX FORMS AVAILABLE AT
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