Quarterly Payment Invoice Form

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MAKE CHECK PAYABLE TO
PHONE (717) 761-4900
WEST SHORE TAX BUREAU
West Shore Tax Bureau
3607 ROSEMONT AVE., P.O. BOX 656
CAMP HILL, PA 17001-0656
Quarterly Payment Invoice
OUR RECORDS INDICATE YOU
ARE A RESIDENT OF:
SOCIAL SECURITY #
QUARTER
YEAR
RATE*
ESTIMATED COMPENSATION
ESTIMATED EARNED INCOME TAX
•
Reason For Reporting Quarterly (check one)
□ Self Employed
□ Employer does not withhold local tax.
□ Employer withheld at a rate less than in effect in
my resident school district/municipality.
Due Dates
1st Quarter 4-30
2nd Quarter 7-31
3rd Quarter 10-31 4th Quarter 12-31
IF ADDRESS IS INCORRECT
❋Enter tax rate used to calculate estimated tax Ex. 1%, 1.7% etc.
QPI (REV 2/02)
CHANGE ABOVE

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