Return Of Income Tax Withheld Form Page 4

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Return of Income Tax Withheld
FOR THE MONTH(S) ENDING
APRIL
CITY OF CENTERVILLE
Income Tax Department
100 W. Spring Valley Road
DUE ON OR BEFORE
Centerville, OH 45458-3759
MAY 15, 2008
Phone 937-433-7151
Fax
937-433-0310
1. AMOUNT SUBJECT
$
Identification No.
TO CENTERVILLE TAX
2. TAX WITHHELD
$
(LINE 1 x 1.75%)
3. AMOUNT ENCLOSED
$
I CERTIFY THAT THE INFORMATION ON THIS RETURN
IS TRUE, CORRECT, AND COMPLETE.
Check here to inactivate this account
Inactive date __________________________
_______________________________________________
Explanation______________________________________
SIGNATURE
TITLE
(
)
________________________________________________
PHONE
DATE

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