Form W-3 - Withholding Tax Reconciliation - Ohio Page 2
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1
2WITHHOLDING TAX RECONCILIATION – PAGE 2
FOR TAX YEAR ENDING
2004
SUBMIT BY FEBRUARY 28. W-2’S MUST BE ATTACHED
Phone (937) 415-2240
BOTH PAGE 1 & PAGE 2 OF THIS RECONCILIATION MUST BE COMPLETED & SUBMITTED BY FEBRUARY 28.
CITY OF VANDALIA
CITY OF ENGLEWOOD
CITY OF BROOKVILLE
JANUARY
APRIL
JULY
OCTOBER
JANUARY
APRIL
JULY
OCTOBER
JANUARY
APRIL
JULY
OCTOBER
$
$
$
$
$
$
$
$
$
$
$
$
FEBRUARY
MAY
AUGUST
NOVEMBER
FEBRUARY
MAY
AUGUST
NOVEMBER
FEBRUARY
MAY
AUGUST
NOVEMBER
$
$
$
$
$
$
$
$
$
$
$
$
MARCH
JUNE
SEPTEMBER DECEMBER
MARCH
JUNE
SEPTEMBER DECEMBER
MARCH
JUNE
SEPTEMBER DECEMBER
$
$
$
$
$
$
$
$
$
$
$
$
1
QTR.
2
QTR.
3
QTR.
4
QTR.
1
QTR.
2
QTR.
3
QTR.
4
QTR.
1
QTR.
2
QTR.
3
QTR.
4
QTR.
ST
ND
RD
TH
ST
ND
RD
TH
ST
ND
RD
TH
$
$
$
$
$
$
$
$
$
$
$
$
6.
Total Paid for year
$
6.
Total Paid for year
$
6.
Total Paid for year
$
I hereby certify that the information and statements contained are true
and correct.
Signed
Title
Fed. ID No.
Date
M A I L TO :
VA N D A L I A TA X O F F I C E
P O B O X 7 2 7
VA N D A L I A , O H 4 5 3 7 7 - 0 7 2 7
Form W-3
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