Employer'S Quarterly Earned Income Tax Return Form - York Adams Tax Bureau
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1EMPLOYER'S QUARTERLY EARNED INCOME TAX RETURN
MAKE CHECKS PAYABLE TO: YATB
1. WAGES SUBJECT TO
$
2. EARNED INCOME TAX-TOTAL ITEM 18
EARNED INCOME TAX
3. CREDIT OR ADJUSTMENT (ATTACH EXPLANATION)
9. QUARTER ENDING DATE
(ITEM #17-TOTALALL PAGES)
4. ADJUST TOTAL OF EARNED INCOME TAX
5. PENALTY AND INTEREST
10. TOTAL PAGES THIS RETURN
$
6. TOTAL TAX DUE
11. TOTAL NUMBER OF EMPLOYEES LISTED
__________________
$
EMPLOYER ACCOUNT NUMBER
7. BALANCE DUE WITH THIS RETURN
12. IF THERE HAS BEEN A CHANGE OF OWNERSHIP OR OTHER
Page
TRANSFER OF BUSINESS DURING THE QUARTER, ATTACH
No.
EXPLANATION AND GIVE NAME OF PRESENT OWNER AND DATE THE
EMPLOYER'S NAME AND ADDRESS
CHANGE TOOK PLACE.
CHANGE
NO CHANGE
13. DO YOU EXPECT TO PAY TAXABLE WAGES NEXT
YES
NO
QTR?
I DECLARE UNDER PENALTIES PROVIDED BY LAW THAT THIS RETURN IS A
COMPLETE STATEMENT AND TO THE BEST OF MY KNOWLEDGE IS A TRUE
AND COMPLETE RETURN.
SIGNED
TAXABLE
TAX
SOCIAL SECURITY
14. NAME OF EMPLOYEE
17.
15.
16.
EMPLOYEES ADDRESS
18.
COMPENSATION
19. PSD
WITHHELD
NUMBER
MAIL TO:
YORK ADAMS TAX BUREAU
TOTAL EARNINGS REPORTED
$
PO BOX 15627
IN COLUMN 17 ON THIS PAGE
YORK PA 17405
TOTAL TAX WITHHELD IN
$
EMAIL:
COLUMN 18 ON THIS PAGE
PHONE: 717-812-0759
TOTAL NUMBER OF EMPLOYEES IN COLUMN 19 ON THIS PAGE
FAX: 717-854-6376
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