Form Eqr/pw3 - Employer'S Municipal Income Tax Withholding 2007 (Page 4 of 7) in pdf

Form Eqr/pw3 - Employer'S Municipal Income Tax Withholding 2007 Page 4

CITY OF PICKERINGTON

2007

FOR PERIOD NO. 1 ENDING ________________

FORM EQR

Quarterly payments due the last day of the following month.

Income Tax Department

Monthly payments due the 15th day of the following month.

100 Lockville Road

Pickerington, Ohio 43147-1321

(614) 837-4116

1. Tax withheld on income earned in Pickerington, (1% rate).

1._________________________

2. Residence tax withheld.

2._________________________

3. Adjustments (explain in full on back of form).

3._________________________

4. Balance Due with this Form. Pay this amount in FULL

4._________________________

5. Late Payment Interest charges 1 1/2% per month from the due date.

5._________________________

6. Late Payment Penalty charges

6._________________________

10% 1-30 Days, 15% 31-60 Days

Total Payment

ACCOUNT NUMBER

20% 61-90 Days, 25% over 90 Days

Make check payable to City of Pickerington.

I HAVE EXAMINED THIS RETURN AND TO THE BEST OF

MY KNOWLEDGE IT IS CORRECT

________________________________________________________

SIGNATURE

TITLE

DATE

________________________________________________________

PRINT NAME

PRINT TITLE

Phone #: ________________________________________________

Form Eqr/pw3 - Employer'S Municipal Income Tax Withholding 2007 Page 4