Local Service Tax Quarterly Coupon - Cumberland County Tax Bureau
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1LOCAL SERVICE TAX QUARTERLY COUPON
1st Quarter 2012 - Due April 30, 2012
Employer Number
Employer Name
Federal EIN
PSD No.
Quarter
1
$
Make check
Total Local Services Tax (LST) withheld..............................................................................................
payable to:
$
Penalty - add 10% of line 1 for each Qtr. Tax remains unpaid (applied to quarterly payment only)...
Mail to: (use tan labels)
$
Interest - add 6% per annum of line 1 for each day (.00017 x # of days) Tax remains unpaid
Cumberland County Tax Bureau
(applied to quarterly payment only)......................................................................................................
$
3607 Rosemont Avenue
Total amount to be remitted with this return. (add lines 1,2,3).....................................................
PO Box 656
X_______________________________Phone_(__ )________
Camp Hill, PA 17001-0656
Return this portion with payment.
(717) 761-4902
Signature
AMOUNT ENCLOSED
I DECLARE UNDER PENALITIES PROVIDED BY THE LAW THAT THIS RETURN HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWL-
EDGE IS A TRUE, CORRECT AND COMPLETE RETURN.
LOCAL SERVICE TAX QUARTERLY COUPON
2nd Quarter 2012 - Due July 31, 2012
PSD No.
Employer Number
Employer Name
Federal EIN
Quarter
2
$
Make check
Total Local Services Tax (LST) withheld..............................................................................................
payable to:
$
Penalty - add 10% of line 1 for each Qtr. Tax remains unpaid (applied to quarterly payment only)...
Mail to: (use tan labels)
$
Interest - add 6% per annum of line 1 for each day (.00017 x # of days) Tax remains unpaid
Cumberland County Tax Bureau
(applied to quarterly payment only)......................................................................................................
$
3607 Rosemont Avenue
Total amount to be remitted with this return. (add lines 1,2,3).....................................................
PO Box 656
Camp Hill, PA 17001-0656
X_______________________________Phone_(__ )________
Return this portion with payment.
(717) 761-4902
Signature
AMOUNT ENCLOSED
I DECLARE UNDER PENALITIES PROVIDED BY THE LAW THAT THIS RETURN HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWL-
EDGE IS A TRUE, CORRECT AND COMPLETE RETURN.
LOCAL SERVICE TAX QUARTERLY COUPON
3rd Quarter 2012 - Due October 31, 2012
PSD No.
Employer Number
Employer Name
Federal EIN
Quarter
3
$
Make check
Total Local Services Tax (LST) withheld..............................................................................................
payable to:
$
Penalty - add 10% of line 1 for each Qtr. Tax remains unpaid (applied to quarterly payment only)...
Mail to: (use tan labels)
$
Interest - add 6% per annum of line 1 for each day (.00017 x # of days) Tax remains unpaid
Cumberland County Tax Bureau
(applied to quarterly payment only)......................................................................................................
$
3607 Rosemont Avenue
Total amount to be remitted with this return. (add lines 1,2,3).....................................................
PO Box 656
X_______________________________Phone_(__ )________
Camp Hill, PA 17001-0656
Return this portion with payment.
(717) 761-4902
Signature
AMOUNT ENCLOSED
I DECLARE UNDER PENALITIES PROVIDED BY THE LAW THAT THIS RETURN HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWL-
EDGE IS A TRUE, CORRECT AND COMPLETE RETURN.
LOCAL SERVICE TAX QUARTERLY COUPON
4th Quarter 2012 - Due January 31, 2013
Employer Number
Employer Name
Federal EIN
PSD No.
Quarter
4
$
Make check
Total Local Services Tax (LST) withheld..............................................................................................
payable to:
$
Penalty - add 10% of line 1 for each Qtr. Tax remains unpaid (applied to quarterly payment only)...
Mail to: (use tan labels)
$
Interest - add 6% per annum of line 1 for each day (.00017 x # of days) Tax remains unpaid
Cumberland County Tax Bureau
(applied to quarterly payment only)......................................................................................................
$
3607 Rosemont Avenue
Total amount to be remitted with this return. (add lines 1,2,3).....................................................
PO Box 656
Camp Hill, PA 17001-0656
X_______________________________Phone_(__ )________
Return this portion with payment.
Signature
(717) 761-4902
AMOUNT ENCLOSED
I DECLARE UNDER PENALITIES PROVIDED BY THE LAW THAT THIS RETURN HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWL-
EDGE IS A TRUE, CORRECT AND COMPLETE RETURN.
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