Annual Reconciliation Of Withholding Taxes Form - Spencer County Page 2

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SCHEDULE OF EMPLOYEES’ WAGES
If Employee W-2 Forms are not reported, Form W-3 must be accompanied with a Schedule of Employees’ Wages
showing: 1) name and address of employee; 2) Social Security number of employee; 3) gross earnings paid before any
payroll deductions; 4) amount of Occupational Taxes withheld for each employee. The total of all occupational taxes
withheld may be reported as one amount for each employee.
SOCIAL
NAME
ADDRESS
GROSS PAY
OCCUPATIONAL TAXES
SECURITYNUMBER
WITHHELD
TOTAL:
0.00
0.00
Revised 11/2011
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