| 1. | Number of Taxable Employees: ___________ | . | Dollars | Cents |
| 2. | Total Salaries, Wages, Commissions and other Compensation Paid all employees (*) | $ | ___________ | .___________ |
| 3. | Less: Non-taxable Items (Compensation paid non-residents for Services outside Mantua) | $ | ___________ | .___________ |
| 4. | Taxable Earnings (Item 2 minus Item 3) | $ | ___________ | .___________ |
| 5. | Actual Tax Withheld in Quarter for City Income Tax | $ | ___________ | .___________ |
| 5a. | Adjustment of Tax for Prior Quarter (see instructions) | $ | ___________ | .___________ |
| 6. | Interest (1/2% per month or fraction thereof) | $ | ___________ | .___________ |
| 7. | Penalty (3% per month or fraction thereof) | $ | ___________ | .___________ |
| . | . |
|
| 8. | TOTAL (Include interest and penalty, if due | $ | ___________ | .___________ |
| * If no wages paid this quarter, mark "None" and return this form with explanation. |
|
| I hereby certify that the information and statements contained herein and in any schedules or exhibits attached are true and correct.
(Signed) .....................................................
(Official Title) .............................................
Owner, Partner, Member, President, Treasurer, Agent
Date........................................................
MAKE CHECK OR MONEY ORDER PAYABLE TO:
VILLAGE OF MANTUA, O. - INCOME TAX
TAX RATE:
ONE AND ONE-HALF PERCENT (1 1/2%)
|
|