Earned Income Tax Withheld - Mifflin County Income Tax Office printable pdf download

Earned Income Tax Withheld - Mifflin County Income Tax Office

Check Applicable Box For Period Filing

MIFFCO TAX SERVICE

Name:___________________________________

Address:_________________________________

□ 01/01/2012 – 03/31/2012 Due 04/30/2012

Mifflin County Income Tax Office

Address:_________________________________

□ 04/01/2012 – 06/30/2012 Due 07/31/2012

City, State Zip:___________________________

□ 07/01/2012 – 09/30/2012 Due 10/31/2012

Earned Income Tax Withheld

□ 10/01/2012 – 12/31/2012 Due 01/31/2013

Employer EIN:___________________________

Employee

Last Name

First Name

Suf

Address

City

Zip Code

Tax w-

Wage

Employee’s

Employer’s

Soc. Sec.

5 digit

held

Psd Cd

Miffco Tax Service Inc.

139 West Market Street

Actual Tax Withheld:__________._____

P.O. Box 746

Lewistown, PA, 17044

(1% Per Month) Interest and Penalty: __________._____

717-242-2777

Total Payment:__________._____

EMPLOYER WITH 25 OR MORE EMPLOYEES CANNOT USE THIS FORM. YOU MUST FILE USING MAGNET MEDIA. CONTACT US FOR SPECIFICATIONS.

Earned Income Tax Withheld - Mifflin County Income Tax Office