Form Eqr - Employer'S Quarterly Return Of Tax Withheld

City of Dover, Ohio

See Instructions

Form EQR

Page 2

Employer’s Quarterly Return of Tax Withheld

1. Taxable Earnings paid all employees subject to

Dover, Ohio, City Income Tax.

$__________________

Actual Tax Withheld in Quarter for City Income Tax

$__________________

3. Adjustment of Tax for prior quarter (see instructions)

$__________________

4. Penalty _____________

Interest___________

$__________________

TOTAL

$__________________

I hereby certify that the information and statements contained herein are true and correct.

(Signed)

(Date)

(Official Title)

THIS RETURN MUST BE FILED

ON OR BEFORE THE DUE DATE SHOWN BELOW

FOR MONTHS OF __________________

DUE ON OR BEFORE________________

MAIL TO:

Income Tax Dept. CITY BUILDING

CITY OF DOVER, OHIO 44622

MAKE CHECK OR MONEY ORDER PAYABLE TO:

CITY OF DOVER, OHIO - INCOME TAX

Notify Income Tax Department Promptly of any change in ownership or name and address shown above

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Parent category: Financial