EFO00116
01-05-12 Record of Idaho Withholding Payments Worksheet

                                             (Calendar Year)

Idaho Income Tax Withholding Summary for:                                             (account number)

 Month   Due Date Date Paid * Taxable Wages Tax Withheld Penalty Paid                                 Interest Paid Amount Paid

January

 February

March

April

May

June

July

 August

September

 October

 November

December

*A payment dated in January will usually be for the prior calendar year.  Include payments for the current calendar year only.

                              Keep this summary for your records.