Reconciliation Of Monthly Returns-Occupational Withholding Tax Form - 2012

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Reconciliation of Monthly Returns
Occupational Withholding Tax
Remittance Address:
Taxpayer Info:
PO Box 830725
Birmingham, AL 35283-0725
(800) 556-7274
FEIN _____________________________________
The following Annual Reconciliation Report is being submitted for:
(please check one)
9756 Beaverton
9359 Hamilton
9677 Mosses
9392 Sulligent
9024 Guin
9375 Midfield
9702 Shorter
7044 Macon County
9000 Haleyville
9625 Tarrant
9335 Tuskegee
_______________
Reconciliation Report for January through December For Year:
Total # of
Total Taxable
Total Occupational Tax
Total Tax Remitted
Employees
Wages for
Withheld from Employees’
for the Above
Diffference Owed
Period Covered
Recorded for the
Employees for
Wages for the Above
Specified Jurisdiction
(if any)
Above Specified
Above Specified
Specified Jurisdiction
Jurisdiction
Jurisdiction
Month ended
$
$
$
$
st
January 31
Month ended
$
$
$
$
th
February 28
Month ended
$
$
$
$
st
March 31
Month ended April
$
$
$
$
th
30
$
$
$
$
Month ended May
st
31
$
$
$
$
Month ended June
th
30
Month ended July
$
$
$
$
st
31
Month ended
$
$
$
$
st
August 31
Month ended
$
$
$
$
th
September 30
Month ended
$
$
$
$
st
October 31
Month ended
$
$
$
$
th
November 30
Month ended
$
$
$
$
December 31st
Total Tax Withheld
$
$
$
$
for Year
st
Note: A copy of this form must be filled out on or before January 31
. Any discrepancy between the total amount withheld and the
total amount remitted must be fully explained in an attached statement. Please enclose payment for difference owed, if any.
Additional Amount Due (if any) $ ________________________
Make checks payable to: Tax Trust Account
I declare, under penalties of perjury, that this return (and any accompanying schedules) has been examined by me and to
the best of my knowledge is true, correct and complete.
Signed:________________________________ Date:____________ Telephone:_________________________
2012 Annual Reconciliation – Occ Tax

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