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               Pleasetchange tax year if necessary
Tax Year                                          WARREN CITY INCOME TAX
FORM W3 1107                                          P.O. BOX 230
 EMPLOYER'S                                       WARREN  OH   44482-0230
 WITHHOLDING
 RECONCILIATION
                                          Voice  330-841-2551 Fax  330-841-2626

            DUE DATE  02/28/

                                                                  FEDERAL ID NUMBER
Name
                                                                  NAME OF PERSON
And                                                               COMPLETING FORM
                                                                  LOCAL PHONE NUMBER
Address
                                                                  NUMBER OF EMPLOYEES LISTED

                      EMPLOYEE W2'S MUST ACCOMPANY THIS FORM
                                                  INSTRUCTIONS
1. Attach check payable to Warren City Income Tax,  for difference if withholding exceeds remittance.
2. If remittance exceeds amount withheld, give explanation and request refund below.
3. Attach explanation if column 2 is used.
Reconciliation and W-2's & 1099-Misc are due February 28

ENTER PAYROLL BY QUARTERLY OR MONTHLY TOTALS
                      (1)                         (2)             (3)               (4)              (5)
                      Gross                       Payroll Not     Payroll           Tax              Tax Paid
Period                Payroll             Subject to Tax      Subject to Tax        Due              Per Your Records

January

February

March/Qtr-1

April

May

June/Qtr-2

July

August

September/Qtr-3

October

November

December/Qtr-4

TOTALS

                                                                  TOTAL REMITTANCE MADE

Employer - Explain any differences:                                                 DIFFERENCE