No                     CITY OF PHILADELPHIA                                                                      SOCIAL SECURITY NUMBER
Staples     ANNUAL RECONCILIATION OF 2018
                    EMPLOYEE EARNINGS TAX
                       DUE DATE APRIL 15, 2019

Taxpayer Name and Address                                                                DO NOT FILE THIS RETURN if tax was 100% withheld on
                                                                                         all  compensation  by  your  employer.    If  tax  was
                                                                                         overwithheld by your employer, file the Employee Wage
                                                                                         Tax Refund Petition available at   www.phila.gov/revenue
                                                                                         in the forms & documents section.
                                                                                         Cancel  this  account  by  entering  the  termination  date
                                                                                         AND file a CHANGE FORM.                                     m m d d                y y y  y

YOU MUST USE A CHANGE FORM TO REPORT A CHANGE OF ADDRESS.
IF YOU ARE NOT ELIGIBLE FOR PA 40 SCHEDULE SP, YOU ARE NOT ELIGIBLE FOR                  If this is an amended return place an "X" here:
INCOME-BASED TAXATION AND CANNOT USE LINES 5, 8, 11, OR 14.

   1.  Gross Compensation received in 2018.  Enclose 2018 W-2 form(s).................................................1.                                                        .00
     2.  Non-taxable gross compensation from Page 2, Line 5.....................................................................2.                                              .00
    3.  Gross taxable compensation (Line 1 minus Line 2)..........................................................................3.                                            .00
         4.Taxable Gross Compensation received by a   resident of Philadelphia
         January 1, 2018 to June 30, 2018..................................................................................................4.                                   .00
         5.Taxable Gross Compensation, eligible for Income-based Rate,
         received by a   resident of Philadelphia January 1, 2018 to June 30, 2018...................................5.                                                         .00
    6.  Tax Due (Line 4 times .038907   OR Line 5 times .033907 if claiming Income-based rate.)...............6.                                                                .00
      7.    Taxable Gross Compensation received by a   resident of Philadelphia
         July 1, 2018 to December 31, 2018................................................................................................7.                                    .00
      8.    Taxable Gross Compensation, eligible for Income-based Rate,
         received by a   resident of Philadelphia July 1, 2018 to December 31, 2018.................................8.                                                          .00
    9.  Tax Due (Line 7 times .038809 OR Line 8 times .033809 if claiming Income-based rate).................9.                                                                 .00
    10.    Taxable Gross Compensation received by a   nonresident of Philadelphia
           January 1, 2018 to June 30, 2018.................................................................................................10.                                 .00
  11.    Taxable Gross Compensation, eligible for Income-based Rate,
         received by a   nonresident of Philadelphia January 1, 2018 to June 30, 2018...........................11.                                                             .00
    12.  Tax Due (Line 10 times .034654   OR Line 11 times .029654 if claiming Income-based rate)...........12.                                                                 .00
  13.    Taxable Gross Compensation received by a   nonresident of Philadelphia
         July 1, 2018 to December 31, 2018..............................................................................................13.                                     .00
  14.    Taxable Gross Compensation, eligible for Income-based Rate,
         received by a   nonresident of Philadelphia July 1, 2018 to December 31, 2018........................14.                                                               .00
  15.  Tax Due (Line 13 times .034567   OR Line 14 times .029567 if claiming Income-based rate)...........15.                                                                   .00
  16.  Total amount of Tax Due (Add Lines 6, 9, 12 and 15).....................................................................16.                                              .00
   17.  Philadelphia Wage Tax withheld by employer or credit for taxes paid to local jurisdictions
          outside of PA. Attach W-2. See Instructions
            If Line 17 is greater than Line 16 file an Employee Wage Tax Petition for this amount...........17.                                                                 .00
    18.  Tax balance due.  (Line 16 minus Line 17.  Cannot be less than zero.)..........................................18.                                                     .00
    19.  Tax that   you,   not your employer, previously paid for 2018. (Not included on W-2 forms)................19.                                                          .00
   20.    TAX DUE  If Line 18 is greater than Line 19,  enter here and in the Tax Due box
          of the Payment Coupon..................................................................................................................20.                            .00
21A.  If Line 18 is less than Line 19, enter amount to be:
          REFUNDED.    Do not file a separate Refund Petition.  Enclose W-2 forms..............................21A.                                                             .00
21B.  Amount of overpayment to be   APPLIED to the 2019 Earnings Tax Return...................................21B.                                                              .00

            Under penalties of perjury, as set forth in 18 PA C.S. §§ 4902-4903 as amended, I swear that I have reviewed this return
            and accompanying statements and schedules, and to the best of my knowledge and belief, they are true and complete.

   Taxpayer Signature________________________________________  Date_______________________Phone #_________________________

   Preparer Signature_________________________________________ Date_______________________Phone #_________________________

                                                                                                                                                     2018 Earnings  3-6-2019
                                                                  Page 1

                                            NON-RESIDENT EMPLOYEE EARNINGS ALLOCATION
                                   AND/OR DEDUCTIBLE EMPLOYEE BUSINESS EXPENSES REPORT

Residents and non-residents of Philadelphia must complete this report to calculate deductible employee business
expenses.  Certain non-residents must complete this report to calculate non-taxable compensation.    If wage tax was
overwithheld by your employer, do not file this return.  File the Employee Wage Tax Refund Petition.

EMPLOYER                                                                                                        EMPLOYEE SOCIAL SECURITY NUMBER

PLACE OF EMPLOYMENT                                                                                             IF PARTIAL YEAR, PROVIDE DATES:
                                                                                                                From                                           To
                                                                                                                EMPLOYER IDENTIFICATION NUMBER (From Form W-2)

                                                                                                                Column A                                         Column B
      Read Instruction Sheets A and B before completing this report.                                            1/1/2018 to 6/30/2018          7/1/2018 to 12/31/2018
1.    GROSS COMPENSATION FOR EMPLOYEES PAID ON A SALARY BASIS per FORM W-2                                                            .00                                .00

     A.  Non-Taxable Compensation (e.g. Stock Options) included in Line 1.  (Must reflect on W-2)                                     .00                                .00

     B.  Adjusted Gross Compensation  (Subtract Line 1A from Line 1)                                                                  .00                                .00
2.  Computation of taxable compensation and/or allowable expenses
     A.  Number of Days/Hours  (Include overtime from Line 2C)                                                  Days/Hours                                          Days/Hours
     B.  Non-workdays/Hours  (Total of weekend, vacation, holiday, sick or any type of leave time)              Days/Hours                                          Days/Hours
     C.  Number of actual Workdays/Hours  (Base_______________Overtime_______________)
           (Line 2A minus Line 2B)                                                                              Days/Hours                                          Days/Hours

     D.  Number of actual Days/Hours worked outside of Philadelphia in Line 2C                                  Days/Hours                                          Days/Hours
     E.  Percentage of time worked outside of Philadelphia  (Line 2D divided by Line 2C)                                              %                                  %

     F.  Non-taxable gross compensation earned outside of Philadelphia  (Line 1B times Line 2E)                                       .00                                .00

G. (i)  Total non-reimbursed business expenses pursuant to Income Tax Regulations Section 204                                         .00                                .00
         (ii)  Multiply amount on Line 2G (i) by the percentage on Line 2E                                                            .00                                .00

         (iii)  Deductible non-reimbursed employee business expenses.  (Subtract Line 2G (ii) from Line 2G (i))                       .00                                .00

     H.  Non-taxable income and/or deductible employee business expenses  (Add Line 2F and Line 2G (iii))                             .00                                .00

3.    GROSS COMPENSATION FOR EMPLOYEES PAID ON A COMMISSION BASIS per FORM W-2                                                        .00                                .00

     A.  Non-Taxable Compensation (e.g. Stock Options) included in Line 3.  (Must reflect on W-2)                                     .00                                .00
     B.  Adjusted Gross Compensation  (Subtract Line 3A from Line 3)                                                                  .00                                .00
4.  Computation of taxable compensation and/or allowable expenses
     A.  Total Sales                                                                                                                  .00                                .00

     B.  Sales earned outside of Philadelphia (Income Regulations 209(b))                                                             .00                                .00
     C.  Percentage of sales outside of Philadelphia.  (Divide Line 4B by Line 4A.)                                                   %                                  %

     D.  Commissions earned outside of Philadelphia.  (Multiply Line 3B by 4C.)                                                       .00                                .00

E. (i)  Total non-reimbursed business expenses pursuant to Income Tax Regulations Section 204                                         .00                                .00

         (ii)  Multiply amount on Line 4E (i) by the percentage on Line 4C                                                            .00                                .00
         (iii)  Deductible non-reimbursed employee business expenses.  (Subtract Line 4E (ii) from Line 4E (i))                       .00                                .00
F.  Non-taxable gross commissions/deductible employee business expenses. (Add Line 4D and Line 4E (iii))                              .00                                .00

5.    TOTAL NON-TAXABLE GROSS COMPENSATION  (Add Lines 2H and Line 4F from Columns A   and B.)                                                                   .00
     Enter here and on Line 2 of the return.
6.    TAXABLE GROSS COMPENSATION (Line 1B minus Line 2H   PLUS Line 3B minus Line 4F)
     Residents enter Column A on Page 1, Line 4 or 5; Non-residents enter Column A on Page 1, Line 10 or 11.                          .00                                .00
     Residents enter Column B on Page 1, Line 7 or 8; Non-residents enter Column B on Page 1, Line 13 or 14.

                                                                                                                                          2018 Earnings P2  9-19-2018
                                                                                         Page 2