City of Wooster, Ohio 

Reconciliation of Municipal Income Tax 
Withheld and Transmittal of W-2 Forms

Please List Business Name, Address, and Taxpayer Identification                For year ending:   
Number Below:
                                                                               File on or before:  02/28

                                  [Copies of all W-2s must be attached]

1. Number of W-2 Forms Attached:                                                  1.
2. Total Amount of Payroll to all Employees: (Sum of box  5on all W2s)            2.
3. Total Wooster Tax Withheld per W-2 Forms:  (Sum of box 19 on all W2s)          3.

                           Schedule of Withholding Tax Payments Made to the City of Wooster

January 31                        April 30                        July 31                  October 31

February28                        May 31                      August 31                    November 30

   March 31                       June 30                     September 30                 December 31

4. Total payments remitted to the City of Wooster                                 4.
5. Balance Due or Overpayment Declared:                                           5.

Box X:   If Box 3 and Box 4 Are Not Equal Please Explain All Discrepancies.  Attach Additional Pages if Needed.
                                  Please Remit any balance due if greater than $10.00

                     W-2 FORMS MUST BE SENT WITH THIS RECONCILIATION

   I CERTIFY THAT THE INFORMATION AND STATEMENTS
       CONTAINED HEREIN ARE TRUE AND CORRECT                              Complete and return with remittance to:  

   NAME:
                                                                               CITY OF WOOSTER
SIGNATURE:                                                                        PO BOX 1088
                                                                           WOOSTER OH  44691-7081
       TITLE:                                                                                                   
                                                                               Phone (330) 263-5226
         DATE: