Transmission Form
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1EXHIBIT A
The City of Brook Park mandates processing withholding tax payments by Electronic Funds
MONTHLY
Transfer (EFT). Included below is a Transmission Form to register for the Tax Connect
AND
ACH-Debit payment system. This form may be used to update banking information. The
QUARTERLY
City also accepts ACH-Credit transmissions; however, attached addenda records must
utilize the approved format. The ACH-Credit registration form and the addenda record
format are available on our website. Please note a penalty will be imposed for failure to
remit taxes by Electronic Funds Transfer or for failure to adhere to the approved addenda
DECEMBER 2014
record format.
DUE 01/15/2015
JANUARY
DUE 02/15/2015
Instructions for the Tax Connect ACH-Debit payment
EXHIBIT B
FEBRUARY
DO NOT USE AS EFFECTIVE
DUE 03/15/2015
system are available on our website. Please be aware
DATES ANY SATURDAY, SUNDAY OR
when selecting effective dates, avoid those shown
FEDERAL OBSERVED HOLIDAYS
MARCH
01/01/2015
09/07/2015
DUE 04/15/2015
in Exhibit B. The effective date must be
01/19/2015
10/12/2015
2 business days in advance and less than
02/16/2015
11/11/2015
APRIL
05/25/2015
11/26/2015
DUE 05/15/2015
30 days in the future.
07/04/2015
12/25/2015
MAY
DUE 06/15/2015
th
See Exhibit A for due dates. As shown, trust funds are due on or before the 15
day
JUNE
DUE 07/15/2015
following the close of the month. Employers who have petitioned and are approved for
quarterly payments should remit on or before the last day of the month following the end of
JULY
DUE 08/15/2015
the calendar quarters (See Note A). Accounts not in compliance will be subject to
assessments. The current rate is 11 ½% per month or fraction thereof. Courtesy withholders
AUGUST
DUE 09/15/2015
please contact the Department of Taxation for remittance forms.
SEPTEMBER
DUE 10/15/2015
(Note A) Employers remitting less than $100.00 per month may petition the Tax Director to
OCTOBER
DUE 11/15/2015
remit on a quarterly basis. Refer to Ordinance 1713.02 (d) on our website
. Call (216) 433-1533 or fax your request to (216) 433-0822 for
NOVEMBER
DUE 12/15/2015
exemption.
DECEMBER 2015
Complete the form below if you are a new employer and need to register or you are an
DUE 01/15/2016
existing company which needs to update banking information
TRANSMISSION FORM
PLEASE PRINT LEGIBLY
ATTACH VOIDED CHECK
CITY OF BROOK PARK TAX ACCOUNT NUMBER__________________________
APPROVED
QUARTERLY
1.) Company Name: __________________________________________________
FID #: __________________________________________________________
JAN - MARCH
04/30/2015
Address: _________________________________________________________
APRIL - JUNE
07/31/2015
2.) Financial Institution Name: ___________________________________________
JULY - SEPT
10/31/2015
3.) Financial Institution’s ABA/Routing Number: _____________________________
OCT – DEC 2015
01/31/2016
4.) Financial Institution’s Account Number: _________________________________
Contact Person: ___________________________________________________
(Please Print Name)
Phone Number: ______________________Fax Number: _____________________
Signature:______________________________________Date:__________________
Information provided on this form is confidential and used for City Income Tax purposes only. NOTE:
Failure to remit by electronic funds transfer or for electronic transactions returned due to incorrect
banking information will subject taxpayer to penalty assessment.
*To begin ACH-Debit payments fax the Transmission Form along with voided check (216) 433-0822*
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