Annual Reconciliation of Withholding Taxes for 2022

                                   City of Mansfield Income Tax Division
                                   P.O. Box 577,  Mansfield, Ohio 44901
                                   Phone: (419)755-9711     Fax: (419)755-9751

              Employer Name & Address          Federal EIN:

                                               Please also submit 1099 forms issued for
                                               compensation related to work performed
                                               in the City of Mansfield

              This reconciliation is due February 28th, 2023 with all employee W-2 forms attached
              LATE FILING OF THIS RETURN IS SUBJECT TO $25.00/MONTH PENALTY, UP TO $150.00
                   If 100 or more W-2s you MUST use Digital Storage Media for reporting

              Withholding Payments remitted
                   for the month of        Number of W-2s enclosed
January
February                                   Total other city compensation paid
March
              Qtr 1
April                                      Total other city tax withheld
May
June                                       Total Mansfield compensation paid
              Qtr 2
July
August                                     Total Mansfield tax withheld
September
              Qtr 3
October                                    Total Mansfield tax paid
November
December                                   Mansfield underpaid (enclosed)
              Qtr 4
                                               Mansfield Overpayment
Total Remitted
                                               Refund                                   Credit to next period

                                   I certify this reconciliation to be true and correct.

              Authorized Signature

              Printed Name

              Title                                         Phone Number

              Contact email address