■ CLGS-32-5 (10-22)                                                                                                                                                                             ■
                                                                                                                                                                  Keystone Collections Group
                                                                                                                                                                  PO Box 559
                                                                               EMPLOYER QUARTERLY RETURN                                                          Irwin, PA 15642-0559
                                                     Local Earned Income Tax Withholding
         You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes by contacting your Tax Officer.  
  Check if making any corrections to EMPLOYER’S Name & Address                                                                 File ONLINE at Business.KeystoneCollects.com
  EMPLOYER BusINEss NAME (use federal ID Name)

  EMPLOYER BusINEss LOCATION - sTREET ADDREss (No PO Box, RD or RR)

  sECOND LINE Of ADDREss

  CITY OR POsT OffICE                                                                                                            sTATE                              zIP

  WORKPLACE LOCATION (city, Borough, township) enter physical address of workplace facility

  COuNTY                                                                                     BusINEss PHONE NuMBER                 BusINEss fAx NuMBER  

  EMPLOYER PsD CODE                    fEDERAL EIN OR sOCIAL sECuRITY #                                    ACCOuNT NuMBER                                           YEAR AND QuARTER

                INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS (No PO Boxes)
  1. Total Earned Income Tax Withheld . . . . . . . . . . . . $                                          8. Date Period Ended (MMDDYYYY)  . . . . . . . . .
                                                                                           .
  2. Credit or Adjustment (attach detail)  . . . . . . . . . . . . $                                     9. Total Pages of This Return . . . . . . . . . . . . . .
                                                                                           .
  3. Total of Earned Income Tax Due (line 1 minus line 2)  . $                                           10. Total Number of Employees Listed  . . . . . .
                                                                                           .
  4. Total Payments Made this Quarter  . . . . . . . . . . . . . $                                       If there has been a change of ownership or other transfer of business during
                                                                                           .
  5. Adjusted Total of EIT Due (line 3 minus line 4) . . . . . . $                                       the quarter, attach explanation and give name of present owner and date the
                                                                                           .             change took place.         CHANGE              NO CHANGE
                                     per month after 
  6. Penalty & Interest ( ___%                             due date x line 5 )  . . . . . $
                                                                                           .
  7. Balance Due with Return (Add lines 5 and 6)  . . . . $                                              Do you expect to pay taxable wages next quarter?               Yes            No
                                                                                           .

                                     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

  sIGNATuRE Of PRIMARY CONTACT INDIvIDuAL                                                                                                                         DATE  (MM/DD/YYYY)

                    INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS (No PO Boxes)

  (11) EMPLOYEE’S SOCIAL              (12) EMPLOYEE’S NAME/ADDRESS                                                  (13) GROSS    (14) AMOUNT OF EIT                        (15) RESIDENT
                                     Check box if making any corrections to EMPLOYEE’S                   COMPENSATION PAID        WITHHELD THIS
     SECURITY NUMBER                            Name/Address, SSN, or Resident PSD                       THIS QUARTER                   QUARTER                             PSD CODE

                                                                                             $                                   $
                                                                                                                               .                .

                                                                                             $                                   $
                                                                                                                               .                .

                                                                                             $                                   $
                                                                                                                               .                .

                                                                                             $                                   $
                                                                                                                               .                .

  (16) FIRST PAGE TOTAL  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $                         $
                                                                                                                               .                .
     Make check payable to: KEYSTONE COLLECTIONS GROUP
     There will be a $29 bank fee for returned payments and checks.                                      TOTAL Amount Enclosed  . . . . . . . $                                                .
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  CLGS-32-5 (10-22) EMPLOYER QUARTERLY RETURN for Local Earned Income Tax Withholding

  Employer federal EIN: ___________________________________________________________________________  Year and Quarter: ______________
                    INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS (No PO Boxes)

  (11) EMPLOYEE’S SOCIAL (12) EMPLOYEE’S NAME/ADDRESS                                                     (13) GROSS         (14) AMOUNT OF EIT (15) RESIDENT
                         Check box if making any corrections to EMPLOYEE’S                                COMPENSATION PAID  WITHHELD THIS
  SECURITY NUMBER            Name/Address, SSN, or Resident PSD                                           THIS QUARTER       QUARTER            PSD CODE

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

                                                                           $                                                $
                                                                                                                     .       .

  (16) THIS PAGE TOTAL  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $                   $
                                                                                                                     .       .
                             When reporting more than 20 employees, file online at business.KeystoneCollects.com
                    INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS (No PO Boxes)
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