Quarterly Payment Invoice Form

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USE THIS MAILING LABEL FOR YOUR PAYMENT
MAKE CHECK PAYABLE TO:
PHONE (717) 761-4900
P
West Shore Tax Bureau
E
WEST SHORE TAX BUREAU
E
3607 ROSEMONT AVENUE
L
3607 ROSEMONT AVENUE
P.O. BOX 656
P.O. BOX 656
H
E
CAMP HILL, PA 17001-0656
CAMP HILL, PA 17001-0656
R
E
OUR RECORDS INDICATE YOU
ARE A RESIDENT OF:
SOCIAL SECURITY #
Quarterly Payment Invoice
Quarterly
Quarterly
QUARTER
YEAR
RATE*
ESTIMATED COMPENSATION
ESTIMATED EARNED INCOME TAX
Reason For Reporting Quarterly (check one)
I I
Self Employed
I I
Employer does not withhold local tax.
I I
Employer withheld at a rate less than in effect in
my resident school district/municipality
Due Dates 1st Quarter 4-30
2nd Quarter 7-31
3rd Quarter 10-31 4th Quarter 1-31
Daytime Phone Number:
IF ADDRESS IS INCORRECT
Enter tax rate used to calculate estimated tax Ex. 1%, 1.7% etc.
*
QPI (REV 6/03)
CHANGE ABOVE

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