Form Pa-W3r - Employer Quarterly Reconciliation Return Of Income Tax Withheld-Replacement Coupon
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1
2EMPLOYER ACCOUNT ID
ENTITY ID (EIN)
PERIOD ENDING DATE
PA-W3R (01-01)
PA DEPARTMENT
OF REVENUE
M M D D Y Y Y Y
SEMI MONTHLY
MONTHLY
PERIOD
PERIOD
AMOUNTS WITHHELD
BUSINESS NAME AND ADDRESS
AMOUNTS WITHHELD
1ST HALF
1ST
L
L
1ST MONTH
MONTH
G
G
LEGAL NAME
2ND HALF
2ND
L
L
1ST MONTH
MONTH
TRADE NAME
G
G
1ST HALF
3RD
L
L
BUSINESS MAILING ADDRESS
2ND MONTH
MONTH
G
G
2ND HALF
CITY, STATE, ZIP
TOTAL
L
L
M LINES 1 – 5 MUST BE COMPLETED. M
2ND MONTH
G
(Enter on Line 2)
G
1. TOTAL COMPEN-
1ST HALF
L
L
L
SATION SUBJECT
L
G
3RD MONTH
TO PA TAX
G
QUARTERLY AMOUNT WITHHELD.
➡
ENTER ON LINE 2 ONLY
2ND HALF
L
L
2. TOTAL PA WITHHOLDING TAX
L
3RD MONTH
G
G
TYPE OF RETURN
ORIGINAL
AMENDED
3. TOTAL DEPOSITS FOR QUARTER
➡
TOTAL
L
L
L
Original or amended. Check block.
(Including verified overpayments)
G
(Enter on Line 2)
G
4. OVERPAYMENT
L
L
MAIL COMPLETED PA-W3R AND PAYMENTS TO:
(If Line 3 is greater than Line 2)
G
DEPARTMENT USE ONLY
PA DEPARTMENT REVENUE
5. TAX DUE/PAYMENT
$
DEPT. 280903
L
L
(If Line 3 is less than Line 2)
G
HARRISBURG, PA 17128-0903
I certify that this return is to the best of my knowledge, information and belief, a full, true and correct disclosure of all tax collected or incurred during the period indicated on this return.
DATE
DAYTIME TELEPHONE #
EXT.
TITLE
SIGNATURE
00019
(
)
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