Employer S Return Of Tax Withheld Form - City Of Springfield Ohio

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CITY OF SPRINGFIELD OHIO, EMPLOYER S RETURN OF TAX WITHHELD
YEAR
PERIOD
AMOUNT ENCLOSED
Tax Rate 2%
AUTHORIZED SIGNATURE
___________
1ST QUARTER
$ __________________
PRINT OR TYPE NAME
DUE ON OR BEFORE ................................ APRIL 30
OFFICIAL TITLE
IS THIS A COURTESY WITHHOLDING? .. • YES
• NO
TELEPHONE NUMBER
IS THIS A FINAL RETURN? ....................... • YES
• NO
E-MAIL ADDRESS
IF YES, EXPLAIN ON REVERSE SIDE.
FEDERAL I.D.
MAKE CHECK PAYABLE TO AND MAIL TO:
COMPANY NAME
CITY OF SPRINGFIELD
ADDRESS
P O BOX 5200
SPRINGFIELD, OH 45501-5200
CITY, ST, ZIP
1
.
FORM QW-1, Page 4

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