Earned Income Tax Quarterly Return Form

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EARNED INCOME TAX QUARTERLY RETURN
MAKE CHECKS PAYABLE TO:
RETURN THIS SECTION TO TAX OFFICE WITH
Your Local CENTAX office serving your area
PAYMENT. PLEASE COMPLETE IN FULL.
A. CHECK QUARTER
B. TAX COMPUTATION
COVERED
JAN 1 - MAR 31
1. Actual or Estimated income
for period.
DUE APRIL 30
2. Tax on Line 1 at rate shown
APR 1 - JUNE 30
at left.
DUE JULY 31
3. Credits (explain on
reverse of form)
JULY 1 - SEPT 30
DUE OCT 31
4. Penalty 1% per mo.
or fraction thereof.
TAX YEAR
TAX RATE
Penalty and interest at 1% per month or fractional
OCT 1 - DEC 31
month will be charged until the tax is paid with a
DUE JAN 31
5. Total Payment Enclosed
minimum
charge
of
$1.50
per
quarter.
*
(2 +4 - 3)
INDICATE ANY CHANGE IN NAME, ADDRESS, OR TAXING DISTRICT
C.
CHECK HERE IF TAX LIABILITY HAS CEASED. EXPLAIN ON REVERSE SIDE OF FORM.
D.
TAX IS WITHHELD BY EMPLOYER:
YES
NO
S.S. NO.
EMPLOYER
ADDRESS
NAME &
ADDRESS
I DECLARE UNDER THE PENALTIES PROVIDED BY LAW THAT THIS DECLARATION HAS BEEN
(PLEASE
EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE IS A TRUE, CORRECT AND COMPLETE
PRINT)
DECLARATION.
DATE:
SS NO.
SIGNATURE:
INDICATE ABOVE CITY, BOROUGH OR TOWNSHIP OF RESIDENCE
* Please contact your local CENTAX office serving your area for the current tax rate

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