INCOME TAX DEPARTMENT 
                                                                                                                   P.O. Box 862 | Findlay, OH 45839-0862
                                                                                    Ph. 419-424-7133 | Fax: 419-424-7410 |  www.findlayohio.gov/incometax 

                                 W-1 Employer’s Quarterly or Monthly Withholding Remittance Form

____________________________________________________                     1. Findlay one percent tax withheld…....____________________________.________ 
Name 

____________________________________________________                     2. Intra-year adjustments……..…………..……____________________________.________ 
Address 

____________________________________________________                     3. Net Findlay one percent liability………..____________________________.________ 
City                                      ST            Zip 

___________-________________________________________                     4. Penalty……….………………………………………..____________________________.________
Federal employer identification number 

___________________                                                      5. Interest………………………………………….……..____________________________.________
Year 

__________________________________                    ____________       6. Payment enclosed……………………….……____________________________.________ 
Month                                            or     Quarter            (Payable to: City of Findlay) 

        I certify, to the best of my knowledge and belief, that the information shown above is true, correct, and complete. 

_____________________________________________________________                        _____________________________________________________________ 
Signature of Responsible Party                                 Date             Title                                   Phone