FORM W-3 ~ MANTUA VILLAGE TAX RECONCILIATION ~ 2016
Employer's Name, address, and FEIN number
File with:
Village of Mantua
Income Tax Dept.
P.O. Box 775
Mantua, Ohio 44255
INSTRUCTIONS
If item 7 indicates overpayment and refund is desired, attach explanation. If additional tax due is indicated, enclose
payment when filing.
The tax ordinance requires the annual preparation and filing of this report, from all employers subject to the tax, on
or before the end of January, 2017.
Other information required to be submitted with this report is the name and address of each employee completely, or
only in part, subject to tax during the tax year, the total gross earnings of each such employee and the amount of tax
withheld from those earnings. If additional space is required, continue on reverse side, or attach additional sheets.
Employers desiring to submit commercially reproduced copies of federal W-2 or electronic reproductions bearing
the required information in either card or listing form may do so in lieu of the listing form.
_____________________
TOTAL MANTUA INCOME TAX
WITHHELD AND REMITTED
Total Number of Employees
$ ____________________
First Quarter (3/31)
$ ____________________
Second Quarter (6/30)
$ ____________________
Total Payroll of the Year
Third Quarter (9/30)
$ ____________________
$ ____________________
Fourth Quarter (12/31)
$ ____________________
Less Payroll Not Subject to Tax
$ ____________________
6. Total Remitted for Year
$ ____________________
Payroll Subject to Tax
$ ____________________
7. Overpayment OR
$ ____________________
Withholding Tax Liability,
1 1/2% of Line 4
8. Additional Tax Due
$ ____________________
LIST OF EMPLOYEES
AMOUNT OF TOTAL
AMOUNT OF VILLAGE
Names and Addresses
GROSS EARNINGS
TAX WITHHELD
.
.