Form Fr-900m - Employer'S/payor'S Withholding Tax Booklet - 2012 Page 39
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47Reconciliation and Report
FR-900B PAGE 2
*129000220000*
Taxpayer name
FEIN/SSN
Telephone number of person to contact
Employer’s DC withholding tax reconciliation
Date Paid
Tax Paid
Explanation
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Under penalties of law, I declare that, to the best of my
knowledge, this return is correct. Declaration of paid preparer
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is based on the information available to the preparer.
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Taxpayer’s
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signature
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Title
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Date
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Paid preparer’s
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signature
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Date
Total for the year
2012 FR-900B P2
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