Or, you can fill in and print the forms below. (Please note that any information that you type into this form will NOT BE SAVED!)
Year:
Account Number:
Tax Rate Per Employee Per Year:
$
Employer Name:
Total Number of Employees Reported:
Address:
Amount Due: (Line 1 X Line 2)
$
Penalty: ($10.00 Late Charge)
$
City/State/Zip:
Total Amount Remitted:
$
Employee SS#
Employee Name
Employee Address
Gross Wages
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Employer's Quarterly Local Services Tax Instructions
This form must be filed quarterly with payment of taxes, covering the preceding quarter.
Enclose check or money order if filing by mail. If a receipt is required, return this form with a stamped, self-addressed envelope and a request.
If your payment is forwarded after the due date indicated on the form, compute and include penalty with your remittance. A $10.00 per quarter late charge from the due date will be assessed.
Failure to file return and pay tax: Failure, refusal or neglect to make a return required or to pay the tax imposed renders the person liable to a fine of $500.00 and costs for each such offense, or to undergo imprisonment.
Do not make any adjustments for prior quarters. Contact this office for adjustment procedures.
If there is not enough space for complete listings of employees, please attach rider. A listing in other form than above
which provides the required data will be acceptable.
A fee of $35 will be charged for any checks returned by the Financial Institution.