Form W 3-                                                                                                     For tax year _______________ 

WITHHOLDING TAX RECONCILIATION 
SUBMIT BY FEBRUARY 28. W-2(S) MUST BE ATTACHED TO THIS RECONCILIATION.                          

CITY OF BROOKVILLE 

                                                                                                             WITHHOLDING TAX REMITTED 
1.  Total number of W-2(s) attached    …….                                         JANUARY                  $ 
                                                         
2.  Total payroll for year ………………...                                               FEBRUARY                 $ 
                                                                                   MARCH                    $ 
3.  Less payroll not subject to tax ……….          
                                                                                   1ST QUARTER              $ 
4.  Payroll subject to tax ………….…….. 
                                                                                   APRIL                    $ 
5.  Withholding tax liability (Line 4  x  2%) …..                                  MAY                      $ 
                                                                                   JUNE                     $ 
                                                                                   2ND QUARTER              $ 
Account # _________________________________________________ 
                                                                                   JULY                     $ 
                                                                                   AUGUST                   $ 
Federal ID # ________________________________________________ 
                                                                                   SEPTEMBER                $ 
                                                                                   3RD QUARTER              $ 
Name _____________________________________________________                    
                                                                                   OCTOBER                  $ 
Address ___________________________________________________                        NOVEMBER                 $ 
                                                                                   DECEMBER                 $ 
__________________________________________________________                         4TH QUARTER              $ 
                                                                                                             
Phone # ___________________________________________________                        TOTAL                    $ 
I hereby certify that the information and statements contained herein are true and 
correct.                                                                           Mail to: VANDALIA TAX OFFICE          
                                                                                               PO BOX 727 
Signed __________________________________________________________ 
                                                                                               VANDALIA, OH 45377-0727         
Official Title __________________________  Date ______________________ 
                                                   
GENERAL INFORMATION 
On or before February 28 of each year, each employer must file a withholding reconciliation on Form W-3.  This reconciliation return must include 
names, addresses, and social security numbers of all employees from whose qualifying wages tax was withheld or should have been withheld for the 
municipal corporation during the preceding calendar year, the amount of tax withheld from each such employee, the total amount of qualifying          
wages paid to such employee during the preceding calendar year, and the name of every other municipal corporation for which tax was withheld or 
should have been withheld from such employee during the preceding calendar year.  Copies of W-2 forms applicable to the reconciliation reporting     
the previously detailed information may be provided as well. 

SPECIFIC FILING INFORMATION                                        
The Form W-3 must show a breakdown of all withholding payments made either quarterly or monthly in the boxes provided.  The amount paid 
and the amount withheld should be equal.  If they are not equal, attach an explanation for any discrepancy.  

If a balance due is indicated, the amount must be paid on or before February 28.  If an overpayment is indicated, amended returns for the month or 
quarter in which the overpayment occurred must be filed.  Refunds will not be issued with this form. 

PHONE (937) 415-2240                                 EMAILtax@vandaliaohio.org                                WEBSITE www.vandaliaohio.org