Annual Reconciliation Of Employee Earnings Tax - City Of Philadelphia - 2015

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CITY OF PHILADELPHIA
SOCIAL SECURITY NUMBER
No
ANNUAL RECONCILIATION OF 2015
Staples
0
2
1
5
EMPLOYEE EARNINGS TAX
DUE DATE APRIL 18, 2016
Taxpayer Name and Address
DO NOT FILE THIS RETURN if tax was 100% withheld on
all compensation by your employer. If tax was overwithheld
by your employer, file the Employee Wage Tax Refund
Petition available at
Cancel this account by entering the termination date AND
file a CHANGE FORM.
m m d
d
y
y
y
y
YOU MUST USE A CHANGE FORM TO REPORT A CHANGE OF ADDRESS.
If this is an amended return place an "X" here:
IF YOU ARE NOT ELIGIBLE FOR PA 40 SCHEDULE SP, YOU ARE NOT ELIGIBLE FOR
INCOME-BASED TAXATION AND CANNOT USE LINES 5, 8, 11, OR 14.
,
,
.00
1. Gross Compensation received in 2015. Enclose 2015 W-2 form(s).....................................................1.
,
,
.00
2. Non-taxable gross compensation from Page 2, Line 5..........................................................................2.
,
,
.00
3. Gross taxable compensation (Line 1 minus Line 2)...............................................................................3.
4. Taxable Gross Compensation received by a resident of Philadelphia
,
,
.00
January 1, 2015 to June 30, 2015.......................................................................................................4.
5. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a resident of Philadelphia January 1, 2015 to June 30, 2015.......................................5.
,
,
.00
6. Tax Due (Line 4 times .0392 OR Line 5 times .0342 if claiming Income-based rate.)...........................6.
7. Taxable Gross Compensation received by a resident of Philadelphia
,
,
.00
July 1, 2015 to December 31, 2015....................................................................................................7.
8. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a resident of Philadelphia July 1, 2015 to December 31, 2015....................................8.
.00
,
,
9. Tax Due (Line 7 times .039102 OR Line 8 times .034102 if claiming Income-based rate)....................9.
10. Taxable Gross Compensation received by a nonresident of Philadelphia
,
,
.00
January 1, 2015 to June 30, 2015....................................................................................................10.
11. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a nonresident of Philadelphia January 1, 2015 to June 30, 2015..............................11.
,
,
.00
12. Tax Due (Line 10 times .034915 OR Line 11 times .029915 if claiming Income-based rate)..............12.
13. Taxable Gross Compensation received by a nonresident of Philadelphia
,
,
.00
July 1, 2015 to December 31, 2015.................................................................................................13.
14. Taxable Gross Compensation, eligible for Income-based Rate,
,
,
.00
received by a nonresident of Philadelphia July 1, 2015 to December 31, 2015...........................14.
,
,
.00
15. Tax Due (Line 13 times .034828 OR Line 14 times .029828 if claiming Income-based rate)..............15.
,
,
.00
16. Total amount of Tax Due (Add Lines 6, 9, 12 and 15)........................................................................16.
17. Any Philadelphia wage tax withheld by employer per enclosed W-2 forms.
,
,
.00
If Line 17 is greater than Line 16 file an Employee Wage Tax Petition for this amount..............17.
,
,
.00
18. Tax balance due. (Line 16 minus Line 17. Cannot be less than zero.)..............................................18.
,
,
.00
19. Tax that you, not your employer, previously paid for 2015. (Not included on W-2 forms).................. 19.
20. TAX DUE If Line 18 is greater than Line 19, enter here and in the Tax Due box
,
,
.00
of the Payment Coupon......................................................................................................................20.
21A. If Line 18 is less than Line 19, enter amount to be:
,
,
.00
REFUNDED. Do not file a separate Refund Petition. Enclose W-2 forms..................................21A.
,
,
.00
21B. Amount of overpayment to be APPLIED to the 2016 Earnings Tax Return......................................21B.
Under penalties of perjury, as set forth in 18 PA C.S. §§ 4902-4903 as amended, I swear that I have reviewed this return
and accompanying statements and schedules, and to the best of my knowledge and belief, they are true and complete.
Taxpayer Signature________________________________________ Date_______________________Phone #_________________________
Preparer Signature_________________________________________ Date_______________________Phone #_________________________
Page 1
0215 Generic 10-7-2015

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