CLGS-32-2 (11-12) 
                                            W2-R ANNUAL RECONCILIATION 
                                      Earned Income Tax Withheld from Wages 
         As reported on Employer’s Quarterly Return (Form E-1); with income tax withheld as shown on Withholding Statements (W-2) 
         You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes. Contact your Tax Officer.             
Year                            Due by the Last Day of February
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EMPLOYER BUSINESS NAME (Use Federal ID Name) 

EMPLOYER BUSINESS STREET ADDRESS (PONoBox, RD or RR) 

SECOND LINE OF ADDRESS 

CITY OR POST OFFICE                                                                                                   STATE                ZIP CODE 
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MUNICIPAL LOCATION OF BUSINESS 

EMPLOYER PSD CODE                                    EMPLOYER ACCOUNT NUMBER                                                       FEDERAL ID NUMBER 

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1. Total number of withholding statements (W-2s) accompanying this report                                                                                         . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
2. Total income tax withheld from all wages during the year as shown on (W-2s)$                                                                  (A)              . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                       EARNED INCOME TAX Tax Paid 
                                                                                             Quarter ended March 31  . . . . . . . . . $ 
                                                                                             Quarter ended June 30  . . . . . . . . . . $ 
                                                                                             Quarter ended September 30  . . . . . $ 
                                                                                             Quarter ended December 31$                                          . . . . . . 
3. Total quarterly income tax from wages during the year as reported on Quarterly Reports  . . . . . . . . . . . . . . . . . . . . . . . . . . . .$(B) 
                                                                                  TOTAL AMOUNT OF ENCLOSED CHECK$ 
4. Any difference between A and B must be explained in attached statement. Where A and B do not agree, please remit or request refund. 

                                Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying 
                                      schedules and statements and to the best of my (our) belief, they are true, correct and complete. 
PRIMARY CONTACT INDIVIDUAL (First Name, Last Name) 

TITLE 

PRIMARY CONTACT PHONE NUMBER                                                    PRIMARY CONTACT EMAIL ADDRESS 
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SIGNATURE OF PRIMARY CONTACT INDIVIDUAL                                                                                  DATE  (MM/DD/YYYY) 
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Instructions for W2-R  Annual Reconciliation Form 

   1. Include municipal location of business in PA, assigned account number and Federal ID number.  Include employer’s full business name and 
   street address. 
   2. On or before the last day of February following the close of the calendar year, file online or return the reconciliation form to appropriate Tax 
   Officer. This form must be accompanied by CITY INCOME TAX copy of the Form W-2 for each employee from whom income tax has been 
   withheld during tax year.  
   3. The total of all income tax withheld as reflected on W-2s should be entered on line 2. Total earned income tax as reported on a quarterly basis 
   should be entered on line 3. 
   4. Please remit any additional monies owed when filing the reconciliation. Attach statement of explanation and include the employee name, SSN, 
   street address, resident PSD code and amount being paid with the reconciliation.