■ CLGS-32-5 (-10 23)                                                                                                                                                                                          ■
                                                                                                                                                                                    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 LOCATIONNo        - sTREET ADDREss (                                   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 SOCIAL                  (12)EMPLOYEE NAME/ADDRESS                                                        (13) GROSS            (14)   EITWITHHELD                           (15) RESIDENT
                                        Check box if making any corrections to EMPLOYEE’S                     COMPENSATION PAID                            THIS
     SECURITY NUMBER                            Name/Address, SSN, or Resident PSD                                         THIS QUARTER                 QUARTER                               PSD CODE
                 Include 9 digits

                                                                                                            $                                   $
                                                                                                                                      .                        .

                                                                                                            $                                   $
                                                                                                                                      .                        .

                                                                                                            $                                   $
                                                                                                                                      .                        .

                                                                                                            $                                   $
                                                                                                                                      .                        .

  (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 23)  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 SOCIAL            (12)EMPLOYEE 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
                 Include 9 digits

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

                                                                                   $                                        $
                                                                                                                     .            .

  (16) THIS PAGE TOTAL  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $                   $
                                                                                                                     .            .
                                     File online at businessKeystoneCollects.com.
                      INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS (No PO Boxes)
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