■ CLGS-32-5 ()6-21                                                                                                                                                                                        ■
                                                                                                                                                                       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 https://Business.KeystoneCollects.com
  EMPLOYER BusINEss NAME (use federal ID Name)

  EMPLOYER BusINEss LOCATIONNo       - sTREET ADDREss (                                    PO Box, RD or RR)

  sECOND LINE Of ADDREss

  CITY OR POsT OffICE                                                                                                              sTATE                                 zIP

  WORKPLACE LOCATION (Provide the name of your city, Borough, township)                                       PHYSICAL ADDRESS OF WORKPLACE LOCATION 

  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 
     SECURITY NUMBER                                                                          EMPLOYEE’S      COMPENSATION PAID      WITHHELD THIS
                                       Name/Address, SSN, (NOorPOResidentBOXES)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-32-510 19 (- )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 corrections to 
  SECURITY NUMBER                                  EMPLOYEE’S                                             COMPENSATION PAID  WITHHELD THIS
                         Name/Address, SSN, (NOorPOResidentBOXES)PSD                                      THIS QUARTER            QUARTER       PSD CODE

                                                                    $                                                       $
                                                                                                                     .            .

                                                                    $                                                       $
                                                                                                                     .            .

                                                                    $                                                       $
                                                                                                                     .            .

                                                                    $                                                       $
                                                                                                                     .            .

                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
                                                                                                                     .            .

                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
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                                                                    $                                                       $
                                                                                                                     .            .

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