Employer S Return Of Tax Withheld - City Of Springfield - State Of Ohio

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Space left blank for office use.
DATE RECEIVED:
ACCOUNT # ________________
Rev. 12/21/10
CITY OF SPRINGFIELD OHIO, EMPLOYER S RETURN OF TAX WITHHELD
YEAR
PERIOD
AMOUNT ENCLOSED
AUTHORIZED SIGNATURE
___________
1ST QUARTER
$ __________________
PRINT OR TYPE NAME
DUE ON OR BEFORE ................................ APRIL 30
OFFICIAL TITLE
IS THIS A COURTESY WITHHOLDING? .. • YES
• NO
TELEPHONE NUMBER
IS THIS A FINAL RETURN? ....................... • YES
• NO
E-MAIL ADDRESS
IF YES, EXPLAIN ON REVERSE SIDE.
FEDERAL I.D.
MAKE CHECK PAYABLE TO AND MAIL TO:
CITY OF SPRINGFIELD
COMPANY NAME
P O BOX 5200
ADDRESS
SPRINGFIELD, OH 45501-5200
CITY, ST, ZIP
1
.
FORM QW-1, Page 4

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