907
                                                                                                                                                R0967A
                                  967  IDAHO ANNUAL WITHHOLDING REPORT                                                                          07-19-2017
         AMENDED                                          ACCOUNT NO.                                          TAX YEAR  DUE ON OR BEFORE
                                                          002566412                                            2021      01/31/2022
   •     Mailing address change •           Cancel account

                                                                                                               Return mailing address:  Idaho State Tax Commission
                                                                                                                         PO Box 76
                                                                                                                         Boise, Idaho 83707-0076
         REVENUE OPERATIONS QUALITY CONTROL
         PO BOX 36
         BOISE ID  83722-0036

Wages and Withholding

1. Total Idaho taxable wages reported on W-2s ..................................................                        •

2. Total Idaho tax withheld on W-2s and 1099s ..................................................                        •

                                                             State use only

                                                          •
                                                          •

3. Total tax paid for calendar year         2021...............................................................         •

4. Remaining tax due or (overpaid). Subtract line 3 from line 2 ..........................                              •

5. Penalty on balance owed. If line 4 is zero or a credit, enter 0 ..........................                           •

6. Interest on balance owed. If line 4 is zero or a credit, enter 0 ..........................                          •

7. Total due.  Add lines 4, 5, and 6 .......................................................................            •

Statements Submitted

8. Number of W-2s for the year    (send W-2s with this form) .............................                              •

9. Number of 1099s with Idaho withholding for the year (send 1099s with this form)•

   Check box if 1099s were submitted through combined federal/state filing ......                                      •

10. Total number of statements. Add lines 8 and 9..................................................                     •

11. Statement penalty. Add after due date.
   Multiply line 10 by $2 per month for each full or part month overdue.
   If submitted by due date, enter 0 .......................................................................            •

12. Add lines 7 and 11
   12a. Total due ....................................................................................................  •

   12b. Total refund ...............................................................................................    •
I certify under penalties of perjury that this return is true, correct and complete to the best of my knowledge.
   Authorized Signature                         Date
•

   1002566412 1002566412 REVE 09 1221 M 67 8