Village of Lordstown                       WITHHOLDING TAX RECONCILIATION                                  (330) 824-2627
lncome Tax DeDartment                                                                                 FAX:  (330)  824-3709
FORM W.3
                                                           Total Lordstown Income  Tax Withheld  Tax Year 20 _.
1. Total number of employees.
                                                           Firstquarter ending March 31       ......  $
2. Totalpayrollfortheyear..  .......  $
                                                           Second  quarter  ending  June 30   . . .. . $
3. Less  payroll  not  subject to tax . .. .. .. .. . .  $ Third  quarter  ending  September 30. . . .
4. Payrollsubjecttotax.      ....  $                       Fourth  quarter  ending December 31 . .    ..  $
                                                           Total remitted  for the year . .
5.Withho|dingtax|iabi|ity@1"/"o|Line4'..$-
                                                           (a)  Overpayment...                ........ $
   EMPLOYER'S NAME, ADDRESS AND ACCOUNT  NUMBER
                                                           (b)  AdditionalTaxDue              ...... $
                                                                         INCOME TAX OFFICE USE  ONLY:

DATE                                                                     AUTHORIZED  SIGNATURE
                                                           INSTRUCTIONS
   ATTACH  FEDERAL W.2 FORM  OR ELECTRONIC REPRODUCTIONS BEARING  THE REQUIRED INFORMATION IN EITHER  CARD
OR LISTING FORM.
   lf item 7(a)  above  indicates  overpayment and refund  is desired,  attach explanation  and request to this Form. lf additional tax due
is indicated, attach  payment  when filing.
   The tax  ordinance requires the annual  preparation and filing of this report  from  all employers subject to the  tax. Reports must  be mailed to
the Village  of Lordstown Income Tax  Department, 1455  Salt Springs Road,  S.W., Lordstown, Ohio 44481 on  or before February 28.
                                                           LORDSTOWN COPY