Form Fr-900a - Employer/payor Withholding Tax - Annual Return - 2012

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2012

FR-900A Employer/Payor

*129000110002*

Government of the

Withholding Tax – Annual Return

District of Columbia

Taxpayer Identification Number

Account Number

Fill in

if FEIN

Clear

OFFICIAL USE ONLY

Fill in

if SSN

Fill in

if final return

Vendor ID#0002

Business name

Due Date

Fill in

if amended return

1/20/2013

Fill in

if non-wage

Mailing address line 1

DC income tax withheld this

year per W-2’s/1099’s

Mailing address line 2

City

State

Zip Code +4

Telephone number of person to contact

Preparer’s PTIN

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.

Taxpayer’s signature

Title

Date

Paid Preparer’s Signature

Date

2012 FR-900A