Form W1 12 - Employer'S Withholding - Monthly

Form W1 12 - Employer'S Withholding - Monthly - 2005 Page 6

FORM W1

998442943

EMPLOYER'S WITHHOLDING - QUARTERLY

1. Number of Taxable Employees. . . . . . . . . . . . . . . . . . . . . . . . .

Tax Year 2005

2. Total Salaries, Wages, Commissions and other

I hereby certify that the information and statements

Compensation paid all employees. . . . . . . . . . . . . . . . . . . . . . . . .

contained here in and in any schedules or exhibits

attached are true and correct.

Signed

3. Taxable Earnings (from line 2). . . . . . . . . . . . . . . . . . . . . . . . . .

Title

Date

4. Actual Tax Withheld at 1.200 %. . . . . . . . . . . . . . . . . . . . . . . . .

THIS RETURN MUST BE FILED ON

5. Adjustments of Tax for Prior Period. . . . . . . . . . . . . . . . . . . . . .

OR BEFORE

JANUARY

31, 2006

6. Interest. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MAKE CHECK OR MONEY ORDER TO:

7. Penalty. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VILLAGE OF EVENDALE

8. Total (Include Interest and Penalty if Due). . . . . . . . . . . . . . . . .

10500 READING RD

Name

EVENDALE OH 45241

And

Voice 513-563-2671

Fax 513-563-2244

Period Ending OCT-NOV-DEC

Address

TAX ID

NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY CHANGE IN OWNERSHIP OR NAME AND ADDRESS.

Form W1 12 - Employer'S Withholding - Monthly - 2005 Page 6