Form It-941 - Employer'S Annual Reconciliation Of Income Tax Withheld

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IT-941
Rev. 11/03
Ohio Tax Withheld–Line 1
Month
Ohio Gross Payroll
January
February
March
April
May
June
July
August
September
October
November
December
Annual Total
Please detach here .
OHIO IT-941
Ohio Employer’s Annual Reconciliation of Income Tax Withheld
Rev. 11-03
Tax Year
Federal Employer ID No.
Ohio Withholding Acct. No.
,
,
1. Ohio Income
Name
$ $ $ $ $
Tax Withheld
,
,
Address
2. Previous
$ $ $ $ $
Payments
City, State, Zip Code
,
,
3. Balance
$
Due
Check here if
Due On or Before:
,
,
,
,
amended return.
$ $ $ $ $
4. Credit
I declare under penalties of perjury that this return, including any accompanying
schedules and statements, has been examined by me and to the best of my
,
,
knowledge and belief is a true, correct and complete return and report.
$ $ $ $ $
5. Refund
Signature of Responsible Party
Title
Telephone No.
DO NOT STAPLE CHECK TO FORM. DO NOT SEND CASH. Make check payable to Treasurer of State
of Ohio and mail to Ohio Department of Taxation, P.O. Box 182667, Columbus, Ohio 43218-2667.
Date
Your Social Security No.

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