Form E-1 - Employer'S Quarterly Earned Income Tax Return
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1*EM11*
PAGE
OF
BERKHEIMER -- EARNED INCOME TAX ADMINISTRATOR
E-1
EMPLOYER'S QUARTERLY EARNED INCOME TAX RETURN
FORM
1
I DECLARE UNDER PENALTY OF LAW THAT THIS
1. TOTAL EARNED INCOME TAX WITHHELD FROM WAGES DURING QUARTER
2
RETURN IS TO THE BEST OF MY KNOWLEDGE A
2. CREDIT OR TOTAL OF ALL MONTHLY PAYMENTS (ATTACH EXPLANATION)
3
TRUE AND COMPLETE RETURN.
3. TOTAL TAX WITHHELD AS ADJUSTED (ITEM 1 MINUS ITEM 2)
4
SIGNED
4. PENALTY AND INTEREST (1% PER MONTH AFTER THE DUE DATE)
5. TOTAL AMOUNT OF TAXES DUE WITH THIS RETURN (ITEM 3 PLUS ITEM 4)
5
TITLE
DATE
6. TOTAL PAGES THIS RETURN
^
7. DATE PERIOD ENDED
TOTAL NO. EMPLOYEES LISTED
OFFICE USE
FEDERAL ID
** SEE INSTRUCTIONS FOR MORE INFORMATION**
^
EM11
▲
ACCOUNT #
▲
LOCATION
Name
Address
City
State
&
Zip
(10) WAGES PAID
(9) EMPLOYEE'S
(11) AMOUNT OF TAX WITHHELD
(12) RESIDENT MUNICIPALITY
(8) NAME/ADDRESS
SOCIAL SECURITY NO.
THIS QUARTER
THIS QUARTER
(CITY, BOROUGH, TOWNSHIP)
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(13) PAGE TOTAL
e102-web 111110
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