Form Eqr - Income Tax Withheld From Wages
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1RECONCILIATION OF NEW LEBANON, OHIO INCOME
TAX WITHHELD FROM WAGES
Form EQR
1. Total number of employees as represented by
W-2 Forms submitted herewith. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Total New Lebanon Income Tax withheld from wages
during ___________ as shown by employee's W -2 Form . . . . . . . . .
3. Total New Lebanon Income Tax Withheld during ____________ for:
Quarter ending March 31, _______
$
Quarter ending June 30, ________
$
Quarter ending Sept. 30, ________
$
Quarter ending Dec. 31, ________
$
4. TOTAL . . . . . . . . . . . . . . . . . . . .
$
5. Difference between Lines 2 & 4
$
FEDERAL IDENTIFICATION NUMBER
NAME OF PERSON FILING
ADDRESS
PHONE NUMBER
"I hereby certify that the information and statements contained herein are true and correct."
(Signed)
Official Title)
Date
If Line 2 is less than Line 4, the amount in Line 5 represents a PAYMENT DUE.
Payment shall accompany this form. If Line 2 is greater than Line 4, the amount in
Line 5 represents a REFUND DUE. A refund request, signed by the employee, should
be made.
W-3
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