AMHERST INCOME TAX DEPARTMENT 
                                                        480 Park Ave 
                                                   Amherst, OH  44001 
                                         Phone (440) 988-4212       Fax (440) 988-3749 
                                                               
                                       COURTESY WITHHOLDING REGISTRATION 
 
Courtesy withholding is payroll tax withheld as a “courtesy” to those employees who are residents of Amherst but do not perform work 
within the City of Amherst.  If your employee is working in another taxing city, the courtesy rate should be 0.5%.   If the employee is not 
withheld elsewhere, the courtesy rate should be 1.5%.  Courtesy withholding is not mandatory. 
 
Company Name:              __________________________________________                Tax ID:  ___________________ 
DBA/Trade Name:            __________________________________________                Date beginning Payroll Withholding 
                                                                                                          ____/____/______ 
Main Office Address:       __________________________________________                Phone: (       ) __________________  
                           __________________________________________                Fax:     (       ) __________________      
Email Address:             __________________________________________                           
   
List below the names and addresses of the employees for whom your company will be remitting resident (courtesy) payroll 
withholding.  If you prefer, the list can be emailed to incometax@amherstohio.org or faxed to (440) 988-3749.  The list will be 
verified by our office to ensure that employees are residents of the City of Amherst.  You will be notified of any issues. 
 
                                                 Amherst Resident Information 
                                                               
Employee Name:      _____________________________________      Employee Name:      _____________________________________   
Employee Address:  _____________________________________       Employee Address:  _____________________________________   
                      _____________________________________                             _____________________________________ 
 
Employee Name:      _____________________________________      Employee Name:      _____________________________________   
Employee Address:  _____________________________________       Employee Address:  _____________________________________   
                      _____________________________________                             _____________________________________ 
 
                                                 Payroll Withholding Information 
                                                               
Withholding Rate            .05%       1.5%     Additional withholding (per employee request)   
  
Remittance Frequency    Monthly (required if over $200 per month)       Quarterly   
          
Mailing Address for        __________________________________________   Payroll Contact Name:   _____________________   
W/H Forms:                 __________________________________________                Phone: (       ) ________________   
                  __________________________________________                                              
                            
OR:         Payroll Service (Your company FEIN is used as the Account Number)                        
          Payroll Company:   ____________________________________________________ 
          Address:             ____________________________________________________    
                               ____________________________________________________ 
          Contact Name / Dept:  __________________________________________________     Phone: (       ) _______________