Earned Income Tax Quarterly Return Form

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EARNED INCOME TAX QUARTERLY RETURN
Central Tax Bureau of Pennsylvania Inc.
PSD :
Select Quarter:
1
CENTRAL TAX BUREAU OF PA, INC. (CENTAX)
Phone:
EARNED INCOME TAX QUARTERLY RETURN
Central Tax Bureau of Pennsylvania Inc.
RETAIN THIS STUB FOR YOUR RECORDS
A. TAX COMPUTATION
QUARTER
ACTUAL OR ESTIMATED
INDICATE ANY CHANGE IN NAME, ADDRESS OR TAXING DISTRICT
1.
INCOME FOR PERIOD
Jan. 1 - Mar. 31 due
1
APRIL 30, 2010
TAX ON LINE 1 AT RATE
2.
SHOWN AT RIGHT
CREDITS (EXPLAIN ON
TAX YEAR:
3.
REVERSE OF FORM)
2010
SOCAL SECURITY #:
PENALTY/INTEREST 1% PER MO.
4.
OR FRACTION THEREOF
TAX RATE:
TOTAL PAYMENT
0.00000
5.
ENCLOSED (2 + 4 - 3)
CENTAX
REMIT PAYMENTS TO THE CENTAX OFFICE LISTED
CHECK IF TAX LIABILITY HAS CEASED, EXPLAIN ON REVERSE OF FORM.
B.
COLLECTOR INFORMATION
FOR TAXPAYER RIGHTS AND OTHER
INFORMATION SEE REVERSE SIDE.
TAX WITHHELD BY EMPLOYER:
YES
NO
C.
MAKE CHECKS PAYABLE TO:
EMPLOYER______________________________________________________________
CENTRAL TAX BUREAU OF PA, INC.
ADDRESS _____________________________________________________________
EARNED INCOME TAX QUARTERLY RETURN
Central Tax Bureau of Pennsylvania Inc.
RETURN THIS SECTION TO TAX OFFICE WITH PAYMENT,
COMPLETE IN FULL.
A. TAX COMPUTATION
QUARTER
ACTUAL OR ESTIMATED
INDICATE ANY CHANGES IN NAME, ADDRESS OR TAXING DISTRICT
1.
Jan. 1 - Mar. 31 due
INCOME FOR PERIOD
1
APRIL 30, 2010
TAX ON LINE 1 AT RATE
2.
SHOWN AT RIGHT
CREDITS (EXPLAIN ON
TAX YEAR:
3.
REVERSE OF FORM)
2010
SOCAL SECURITY #:
PENALTY/INTEREST 1% PER MO.
4.
OR FRACTION THEREOF
TAX RATE:
TOTAL PAYMENT
0.00000
5.
ENCLOSED (2 + 4 - 3)
CENTAX
REMIT PAYMENTS TO THE CENTAX OFFICE LISTED
CHECK IF TAX LIABILITY HAS CEASED, EXPLAIN ON REVERSE OF FORM.
B.
I DECLARE UNDER THE PENALTIES PROVIDED BY LAW THAT THIS DECLARATION
HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE IS A TRUE,
TAX WITHHELD BY EMPLOYER:
YES
NO
CORRECT AND COMPLETE DECLARATION.
C.
EMPLOYER______________________________________________________________
DATE:________________________ S.S.NO._______________________________________
ADDRESS ______________________________________________________________
SIGNATURE:

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