Form Fr-900a - Employer'S/payor'S Withholding Tax - 2011 Page 13

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*119000110000*
2011
FR-900A Employer/Payor
Government of the
District of Columbia
Withholding Tax – Annual Return
Important: Print in CAPITAL letters using black ink.
Taxpayer Identification Number
Fill in
if FEIN
Fill in
if final return
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OFFICIAL USE ONLY
Fill in
if SSN
Fill in
if amended return
VENDOR ID#0000
Business name
.
DC income tax
.
$
withheld this year
Mailing address line 1
Account Number
Due Date
Mailing address line 2
1/20/2012
Telephone number of person to contact
Preparer’s PTIN
City
State
Zip Code +4
Under penalties of law, I declare that, to the best of my knowledge, this return is correct. Declaration of paid preparer is based on the information available to the preparer.
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Taxpayer’s signature
Title
Date
Paid Preparer’s Signature
Date
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2011 FR-900A

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