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KS-1338_Layout 1 12/12/13 1:41 PM Page 1
KS-1338_Layout 1 12/12/13 1:41 PM Page 1
KS-1338_Layout 1 12/12/13 1:41 PM Page 1KS-1338_Layout 1 12/12/13 1:41 PM Page 1KS-1338_Layout 1 12/12/13 1:41 PM Page 1
KS-1338_Layout 1 12/12/13 1:41 PM Page 1KS-1338_Layout 1 12/12/13 1:41 PM Page 1
KS-1338_Layout 1 12/12/13 1:41 PM Page 1KS-1338_Layout 1 12/12/13 1:41 PM Page 1KS-1338_Layout 1 12/12/13 1:41 PM Page 1
ANNUAL PAYROLL RECONCILIATION
ANNUAL PAYROLL RECONCILIATION
City of Canton, Income Tax DepartmentCity of Canton, Income Tax DepartmentANNUAL PAYROLL RECONCILIATIONANNUAL PAYROLL RECONCILIATIONANNUAL PAYROLL RECONCILIATIONKIM R. PEREZKIM R. PEREZ
KS-1338_LayoutP.O.CityP.O.CityANNUALANNUALofofBOXBOXCanton,Canton,1 9940 9940 12/12/13 IncomeIncome• • TaxTax4244241:41DepartmentDepartmentMARKETMARKETPM PAYROLLPAYROLLPageN.,N.,1CANTON,CANTON,OHIOOHIO44711 44711 • • PHONEPHONERECONCILIATIONRECONCILIATION(330)(330)430-7900430-7900 TREASURER,TREASURER,CITYCITYKIM R. PEREZKIM R. PEREZOFOFCANTONCANTON
P.O.P.O.cantonincometax.comCity ofBOXBOXCanton,9940 9940 Income• • Tax424424DepartmentMARKETMARKET N.,N., CANTON,CANTON, OHIOOHIO 44711 44711 • • PHONEPHONE (330)(330) 430-7900430-7900 TREASURER,TREASURER, CITYCITYHOURS:KIM R. PEREZOFOF8:00CANTONCANTON- 4:00
cantonincometax.comcantonincometax.comP.O.CityANNUALANNUALofBOXCanton,9940 Income• Tax424DepartmentMARKETPAYROLLPAYROLLN., CANTON, OHIO 44711 • PHONERECONCILIATIONRECONCILIATION(330) 430-7900 TREASURER,MondayCITYHOURS:HOURS:KIM R. PEREZthrough8:008:00OF CANTON--Friday4:004:00
P.O.cantonincometax.comP.O.BOXBOX9940 9940 • • 424424 MARKETMARKETN.,N.,CANTON,CANTON,OHIOOHIO44711 44711 • • PHONEPHONE(330)(330)430-7900430-7900 TREASURER,MondayMondayMondayMondayCITYHOURS:throughthroughthroughthrough8:00OF CANTON-FridayFridayFridayFriday4:00
cantonincometax.comP.O.City ofBOXCanton,9940 Income• Tax424DepartmentMARKET N., CANTON, OHIO 44711 • PHONE (330) 430-7900 TREASURER, CITYHOURS:KIM R. PEREZOF8:00CANTON- 4:00
CityCityP.O.ANNUALofofBOXCanton,Canton,9940 IncomeIncome• TaxTax424DepartmentDepartmentMARKETPAYROLLN., CANTON, OHIO 44711 • PHONERECONCILIATION(330) 430-7900 TREASURER,TREASURER,MondayMondayCITYCITYKIM R. PEREZKIM R. PEREZthroughthroughOFOF CANTONCANTONFridayFriday
CityP.O.cantonincometax.comcantonincometax.comcantonincometax.comofBOXCanton,9940 Income• Tax424DepartmentMARKET N., CANTON, OHIO 44711 • PHONE (330) 430-7900 TREASURER, CITYHOURS:HOURS:HOURS:KIM R. PEREZOF8:008:008:00CANTON--- 4:004:004:00
cantonincometax.comcantonincometax.com 2023 MondayHOURS:HOURS:through8:008:00--Friday4:004:00
Monday through FridayMonday through Friday
EMPLOYER I.D. NO.EMPLOYER I.D. NO.
ANNUAL PAYROLL RECONCILIATIONEMPLOYER I.D. NO.
City of Canton, Income Tax Department ACCOUNT NUMBEREMPLOYER I.D. NO.EMPLOYER I.D. NO.EMPLOYER I.D. NO. KIM R. PEREZ
OTHER EIN USEDEMPLOYER I.D. NO.
P.O. BOX 9940 • 424 MARKET N., CANTON, OHIO 44711 • PHONE (330) 430-7900 OTHER EIN USEDEMPLOYER I.D. NO. TREASURER, CITY OF CANTON
cantonincometax.com OTHEROTHEREMPLOYEREMPLOYEREINEIN USEDUSEDI.D.I.D.NO.NO. HOURS: 8:00 - 4:00
OTHER EIN USED
EMPLOYEROTHER EINTaxUSEDI.D.Athority:NO. Monday through Friday
OTHER EIN USED
All W-2’s, or a computer printout or magneticOTHER EINmediaUSED
All W-2’s, or a computer printout or magneticOTHER EINmediaUSEDCity of Canton JEDD District TWR/SS
AllcontainingW-2’s,W-2or adatacomputerMUST BEprintoutENCLOSED.or magnetic media
AllAllcontainingW-2’s,W-2’s,W-2oror aadatacomputercomputerMUSTprintoutprintoutBE ENCLOSED.oror magneticmagneticOTHER EINmediamediaUSEDJEDD District SM JEDD District FP
AllAllcontainingcontainingW-2’s,W-2’s,W-2W-2oror aadatadatacomputercomputerMUSTMUST BEBEprintoutprintoutENCLOSED.ENCLOSED.oror magneticmagnetic mediamedia
containing W-2 data MUST BE ENCLOSED.
PART 1 - ACCOUNT INFORMATIONAllAllAllcontainingcontainingW-2’s,W-2’s,W-2’s,W-2W-2orororaaadatadatacomputercomputercomputerMUSTMUSTprintoutBEBEprintoutprintoutENCLOSED.diaENCLOSED.diaororormagneticmagneticmagneticEMPLOYERmememediaI.D.JEDDNO.District CD JEDD District TSG
PART 1 - ACCOUNT INFORMATIONcontaining W-2 data MUST BE ENCLOSED.
PART 1 - ACCOUNT INFORMATIONcontaining W-2 data MUST BE ENCLOSED.JEDD District TGAB JEDD Faircrest
TYPE OF ACCOUNT:PART 1 - ACCOUNT INFORMATIONPART 1 - ACCOUNT INFORMATIONcontaining W-2 data MUST BE ENCLOSED.OTHER EIN USED
TYPE OF ACCOUNT:PART 1 - ACCOUNT INFORMATIONPART 1 - ACCOUNT INFORMATION
TYPE OF ACCOUNT: Contact Person
TYPE OF ACCOUNT:TYPE OF ACCOUNT:TYPE OF ACCOUNT:TYPE OF ACCOUNT:PART 1 - ACCOUNT INFORMATIONPART 1 - ACCOUNT INFORMATIONPART 1 - ACCOUNT INFORMATIONResident Employer Withholding Canton Tax Only
Resident Employer Withholding Canton Tax Only Contact Person
Contact Person
Resident Employer Withholding Canton Tax Only Contact PersonContact Person
TYPE OFNon-ResidentResidentResidentACCOUNT:EmployerEmployerEmployerWithholdingWithholdingDoing BusinessCantonCantonAllinW-2’s,TaxTaxCantonOnlyOnlyor a computer printout orPhonemagneticNo. media
TYPE OF ACCOUNT:Non-Resident Employer Doing Business in Canton Phone No.Contact Person
Contact Person
ResidentResident EmployerEmployer WithholdingWithholding CantonCanton TaxTax OnlynOnly
TYPE OFEmployerResidentNon-ResidentEmployerNon-ResidentResidentNon-ResidentACCOUNT:Employer(EitherEmployer(EitherEmployerEmployerEmployerResidentResidentWithholdingWithholdingDoingDoingDoingororBusinessBusinessBusinessNon-Resident)Non-Resident)CantonCantoncontaininginininTaxTaxCantoCantonCantonW-2OnlygOnlydoingdoingdata MUST BE ENCLOSED.FaxPhoneFaxPhonePhonePhoneNo.No.No.No.No.No.
Non-Resident Employer Doing Business in Canton Contact PersonContact Person
BusinessNon-Residentin CantonEmployerand otherDoingOhioBusinessCities/JEDDS/Townshipsin Canton
BusinessEmployerEmployerin(Either(EitherCanton andResidentResidentotherororOhioNon-Resident)Non-Resident)Cities/JEDDS/Townshipsdoingdoin FaxFaxContactPhoneNo.No.No.Person
Courtesy Withholding AccountBusiness in Canton and other Ohio Cities/JEDDS/Townships
PARTResidentBusinessNon-ResidentBusinessEmployerEmployerNon-Resident1 -ininEmployerACCOUNT(Either(EitherCantonCantonEmployerEmployerandandResidentResidentWithholdingINFORMATIONotherotherDoingDoingororOhioOhioBusinessBusinessNon-Resident)Non-Resident)CantonCities/JEDDS/TownshipsCities/JEDDS/TownshipsininCantonTaxCantondoingdoingOnly PhoneE-MailFaxFaxPhoneNo.No.No.No.Address
Business in Canton and other Ohio Cities/JEDDS/Townships
CourtesyCourtesyNon-ResidentCourtesyEmployerEmployerBusiness inWithholdingWithholdingWithholding(Either(EitherCantonEmployerandResidentResidentAccountAccountAccountotherDoingororOhioBusinessNon-Resident)Non-Resident)Cities/JEDDS/Townshipsin Cantondoingdoing E-MailE-MailPhoneE-MailE-MailFaxFax No.No.No.AddressAddressAddressAddress
PARTCourtesyEmployerEmployerBusinessCourtesy2 RECONCILIATIONinWithholdingWithholding(Either(EitherCanton andResidentResidentAccountAccountotherororOhioNon-Resident)Non-Resident)OFCities/JEDDS/TownshipsFEDERALdoingdoingWAGES FaxFaxE-MailE-MailNo.No. AddressAddress
TYPEPARTOFBusinessCourtesyACCOUNT:2 RECONCILIATIONinWithholdingCanton andAccountother OhioOFCities/JEDDS/TownshipsFEDERAL WAGES
PARTCourtesy2 RECONCILIATIONWithholding AccountOF FEDERAL WAGES E-Mail Address
MedicareMedicarePARTPARTCourtesyBusinessCourtesy22TaxableTaxableRECONCILIATIONRECONCILIATIONinWithholdingWithholdingCantonWagesWagesand(From(FromAccountAccountotherBoxBoxOhio55OFOFofofCities/JEDDS/TownshipsFormsFormsFEDERALFEDERALW-2)W-2) WAGESWAGES ContactE-MailE-MailAddressAddressPerson
Resident Employer Withholding Canton Tax Only
MedicareMedicarePARTPARTAdd: 22TaxableTaxableRECONCILIATIONRECONCILIATION-WagesWagesOrdinary(From(FromincomeBoxBoxfrom55OFOFofoftheFormsFormsFEDERALFEDERALexerciseW-2)W-2) WAGESWAGESof stock
MedicareAdd: Taxable- OrdinaryWages (FromincomeBoxfrom5 oftheFormsexerciseW-2) of stock
MedicareMedicarePARTPARTNon-Resident22TaxableTaxableRECONCILIATIONRECONCILIATIONoptionsWagesWagesEmployerexcluded(From(FromDoingBoxBoxfromBusiness55OFOFMedicareofof FormsFormsFEDERALFEDERALin CantonW-2)W-2)wages.WAGESWAGES Phone No.
Add: - Ordinary income from the exercise of stock
MedicarePARTAdd: Add: 2TaxableRECONCILIATIONoptions--OrdinaryOrdinaryWagesexcluded(FromincomeincomeBoxfromfromfrom5OFMedicareofthetheFormsFEDERALexerciseexerciseW-2)wages.WAGESofofstockstock
Employer (Either Resident or Non-Resident) doing- Supplemental unemployment compensation Fax No.
options excluded from Medicare wages.
MedicareMedicareBusinessAdd: Add: TaxableTaxablein-optionsoptionsSupplemental--CantonWagesWagesOrdinaryOrdinaryexcludedexcludedand(From(FromincomeincomeotherunemploymentBoxBoxfromfromOhiofromfrom55MedicareMedicareofofCities/JEDDS/TownshipsthetheFormsFormsexerciseexerciseW-2)W-2)compensationwageswages.. ofof stockstock
Add: Add: --(“sub-pay”)optionsoptions-SupplementalSupplemental-OrdinaryOrdinaryexcludedexcludedincomeincomeexcludedunemploymentunemploymentfromfromfromfromMedicareMedicarefromthetheMedicareexerciseexercisecompensationcompensationwages.wages.ockofwages.ofststock
-(“sub-pay”)Supplementalexcludedunemploymentfrom Medicarecompensationwages.
CourtesyAdd: Less: --Withholdingoptions(“sub-pay”)(“sub-pay”)options--SupplementalSupplementalWagesOrdinaryexcludedexcludedNotincomeAccountexcludedexcludedSubjectunemploymentunemploymentfromfromfromMedicareMedicarefromfromtotheCantonMedicareMedicareexercisecompensationcompensationwages.wages.Taxwages.wages.of(Explain)stock E-Mail Address
Less: (“sub-pay”)- Wages NotexcludedSubjectfromto CantonMedicareTaxwages.(Explain)
Less: Less: ---options(“sub-pay”)(“sub-pay”)--SupplementalOtherSupplementalWagesWages(Explain)excludedNotNotexcludedexcludedSubjectSubjectunemploymentunemploymentfrom Medicarefromfromtoto CantonCantonMedicareMedicarecompensationcompensationwages.TaxTaxwages.wages.(Explain)(Explain)
PARTLess: 2 RECONCILIATION--OtherWages(Explain)Not SubjectOFtoFEDERALCanton TaxWAGES(Explain)
CantonLess: Less: ---(“sub-pay”)(“sub-pay”)TaxableOtherOther--SupplementalWagesWages(Explain)(Explain)NotNotWagesexcludedexcludedSubjectSubjectunemploymentfromfromtoto CantonCantonMedicareMedicarecompensationTaxTaxwages.wages.(Explain)(Explain)
MedicareCantonTaxable-TaxableOtherWages(Explain)Wages
Less: CantonCantonAdd:NLess: --No.(“sub-pay”)TaxableTaxable--OtherOtherofWagesWagesW-2’s(Explain)(Explain)NotNot(FromWagesWages AttachedexcludedSubjectSubjectBox 5fromtooftoCantonCantonFormsMedicareW-2)TaxTaxwages.(Explain)(Explain)
Add:NCanton Taxable Wages No. of W-2’s Attached
Less: Add: Add:NAdd:NCantonCantonNo.--No.No.TaxableTaxable--OtherOtherofofofWagesOrdinary1099W-2’sW-2’s(Explain)(Explain)StatementsNotWagesWages incomeAttachedAttachedSubjectfromAttachedtheto CantonexerciseTaxof(Explain)stock
Add:NNo.No.ofof1099W-2’sStatementsAttached Attached
CantonCantonAdd:NAdd:NTotalNo.No.-No.No.optionsTaxableTaxableOtherofofofof109910991099W-2’sW-2’s(Explain)excludedAmountStatementsStatementsWages WagesAttachedAttachedfromAttachedAttachedMedicare wages.
Total 1099 AmountNo. of 1099 Statements Attached
CantonAdd:NAdd:NTotalTotalNo.No.-No.No.TaxableSupplementalofofofof1099109910991099W-2’sW-2’sAmountAmountStatementsStatementsWagesAttachedAttachedunemploymentAttachedAttachedcompensation
PART 3 RECONCILIATIONTotal 1099 Amount OF TAX WITHHELD
PART 3 RECONCILIATION OF TAX WITHHELD
PARTPARTAdd:N33RECONCILIATIONRECONCILIATIONNo.TotalTotalNo.No.(“sub-pay”)ofofof1099109910991099W-2’sAmountAmountStatementsStatementsAttachedexcludedAttachedAttachedOFOFfromTAXTAXMedicareWITHHELDWITHHELDwages.
CantonPARTPARTTaxable33RECONCILIATIONRECONCILIATIONTotalNo.TotalWagesof109910991099SubjectAmountAmountStatementsTo TaxAttachedFromOFOFatTAXTAX2% (WITHHELDWITHHELDPart 2) X 2%
PARTPARTAdd:Less: 33TotalRECONCILIATIONRECONCILIATION- Wages1099 AmountWagesNot SubjectSubjectOFOFto CantonTAXTAXToWITHHELDWITHHELDTaxTax(Explain)At Less Than 2% X___%
Canton Taxable Wages Subject To Tax at 2% (From Part 2) X 2%
CantonCantonTaxableTaxableWagesWages SubjectSubjectTo Tax at 2.5To%Tax(FromatPart2%2)(From Part 2) _______________ X 2% X 2.5% _______________
CantonCantonPARTPARTAdd:TaxableTaxable33(i.e.RECONCILIATIONWagesRECONCILIATION- OtherWagesWagescourtesySubject(Explain)SubjectSubjectwithholding,To TaxToToTaxTaxother,AtOFOFatatLessexplain)TAXTAX2%2%Than(From(FromWITHHELDWITHHELD2%PartPart2)2) XX___%X2%2%
WagesCantonCantonSubjectAdd:Add:CantonTaxableTaxableto(i.e.WagesWagesTaxTaxableWagesWagesatcourtesylessSubjectSubjectthanSubjectSubjectwithholding,Wages2.5%ToTo(i.e.TaxTaxcourtesyToToother,TaxTaxAtAtwithholding,atatLessLessexplain)2%2%ThanThan(From(Fromother,2%2%PartPartexplain) 2)2) _______________ X___%X___%XX 2%2% X __% _______________
Add: (i.e. courtesy withholding, other, explain)Wages Subject To Tax At Less Than 2% X___%
CantonCantonPARTTotalAdd:TaxableAdd:NAdd:Taxable3Canton(i.e.(i.e.RECONCILIATIONTotalWagesNo.WagesWagesofIncomecourtesycourtesyCantonSubjectW-2’sSubjectSubjectTaxwithholding,withholding,AttachedDue IncomeTo TaxToToTaxother,Taxother,TaxAtOFDueatatLessexplain)explain)TAX2%2%Than(From(FromWITHHELD2%PartPart2)2) XXX___%2%2% _______________
Add: Add: Total Canton Income Tax DueWages Subject To Tax At Less Than 2% X___%
Add: Total Canton Income Tax Due
CantonTotalAdd:Add:Add:TaxableAdd:Canton(i.e.(i.e.TotalTotalTotalNo.WagesWagesofIncomecourtesycourtesyCantonCantonCantonSubject1099SubjectTaxStatementswithholding,withholding,Withheld IncomeIncomeIncomeTo TaxToTaxTaxTaxTaxother,other,AttachedAtDueDueWithheldatLessexplain)explain)2%Than(From2%Part 2) XX___%2% _______________
Add: Total Canton Income Tax Withheld
Add:Add:Add:Add:Add:Add:(i.e.WagesWagesTotalTotalTotalTotalcourtesyCantonCantonCantonCantonSubjectSubjectwithholding,IncomeIncomeIncomeIncomeToToTaxTaxTaxTaxTaxTaxother,AtAtWithheldWithheldDueDueLessLessexplain)ThanThan2%2% X___%X___%
Add: (i.e. courtesy withholding, other, explain)Total Canton Income Tax Withheld
PARTWAGES:Add:Add:Add:Add:4(i.e.RECONCILIATIONTotalTotalTotalTotalTotal Entercourtesyon1099CantonCantonCantonCantonlinesAmountwithholding,1 throughIncomeIncomeIncomeIncome24TaxTaxTaxTaxtheother,OFamountDueDueWithheldWithheldexplain)DEPOSITSpaid for each Semi-Monthly filling period.
PARTPARTAdd:Add:44RECONCILIATIONDEPOSITTotalTotalCantonCantonDETAILIncomeIncome TaxTaxOFWithheldDueDEPOSITS
QuarterPARTPARTPARTPARTAdd:Ended4443RECONCILIATIONRECONCILIATIONRECONCILIATIONRECONCILIATIONTotal03/31 Canton Income TaxOFOFOFOFWithheldDEPOSITSDEPOSITSDEPOSITSTAX WITHHELD
PARTAdd:4 RECONCILIATIONTotal Canton Income TaxOFWithheldDEPOSITS
Quarter Ended 03/31
CantonQuarterQuarterPARTTaxableEndedEnded4 RECONCILIATION03/3106/30Wages OF DEPOSITS
Quarter Ended 03/31Quarter Ended 09/30Quarter Ended 03/31Quarter Ended 03/31Quarter Ended 03/31PART 4 RECONCILIATION OF DEPOSITSPART 4 RECONCILIATION OF DEPOSITSPART 4 RECONCILIATION OF DEPOSITSSubject To Tax at 2% (From Part 2) X 2%
QuarterAdd:EndedWages06/30 Subject To Tax At Less Than 2% X___%
Quarter Ended 06/30
Quarter Ended 09/30Quarter Ended 06/30Quarter Ended 06/30(i.e. courtesy withholding, other, explain)
Quarter Ended 12/31Quarter Ended 09/30
QuarterQuarterQuarterQuarterQuarterQuarterQuarterAdd:EndedEndedEndedEndedEndedEndedEndedTotal03/3109/3009/3012/3106/3003/3106/30 Canton Income Tax Due
TotalQuarterCantonEndedIncome12/31 Tax Paid
QuarterQuarterQuarterQuarterTotalQuarterQuarterQuarterCantonAdd:EndedEndedEndedEndedEndedEndedEndedTotal06/3012/3112/3103/31Income06/3009/3009/30CantonTaxIncomePaid Tax Withheld
GreaterTotalQuarterTotalQuarterQuarterQuarterQuarterCantonCantonofEndedEndedEndedEndedEndedTax09/30IncomeIncome06/3012/3112/3109/30DueTaxor WithheldTaxPaidPaid (From Part 3)
GreaterTotal Cantonof TaxIncomeDue or WithheldTax Paid (From Part 3)
BalanceQuarterQuarterGreaterGreaterTotalQuarterTotal CantonCantonofofEndedEndedEndedDueTaxTax/12/31r09/3012/31rIncomeIncomeDueDueOverpayment ooWithheldWithheldTaxTax PaidPaid[Transfer(From(FromPartPartCredit]3)3)
BalanceGreaterPARTof4DueTaxRECONCILIATION/DueOverpayment or Withheld[Transfer(FromOFPartCredit]DEPOSITS3)
BalanceBalanceTotalQuarterGreaterGreaterTotalCantonCantonofofEndedDueDueTaxTax//Income12/31IncomeDueDueOverpayment Overpayment oror WithheldWithheldTaxTaxPaidPaid[Transfer[Transfer(From(From PartPartCredit]Credit]3)3)
TotalBalanceCantonDueIncome/TaxOverpayment Paid [Transfer Credit] _______________
QuarterGreaterTotalUnderBalanceBalanceGreaterPenaltiesCantonofofEndedDueDueTaxTax//of03/31IncomeDueDueOverpayment Overpayment perjury,ororWithheldWithheldTaxIPaiddeclare[Transfer[Transfer(From(FromthatPartPartCredit]Credit]I have3)3) examined this return and accompanying documents, and,
Under Penalties of perjury, I declare that I have examined this return and accompanying documents, and,
GreaterBalanceGreaterQuartertoUnderUnderBalancethePenaltiesPenaltiesofbestofTaxEndedDueDueofTaxDue//ofof06/30myorDueWithheldOverpayment Overpayment perjury,perjury,knowledgeor Withheld(FromIIanddeclaredeclarePart[Transfer[Transferbelief,3) (FromthatthatParttheyCredit]Credit]II havehaveare3)examinedexaminedtrue, correct,thisthis returnreturnandandandcomplete.accompanyingaccompanying documents,documents, and,and, _______________
BalancetoBalanceQuartertotoUnderUnderthethethePenaltiesPenaltiesbestbestbestDueEndedDue/ofofofOverpayment/ofof09/30mymymyOverpayment perjury,perjury,knowledgeknowledgeknowledge[TransferIIandandanddeclaredeclareCredit] belief,belief,[Transferbelief,thatthattheytheytheyCredit]IIhavehaveareareareexaminedexaminedtrue,true,true,correct,correct,correct,thisthisreturnreturnandandandcomplete.complete.complete.andandaccompanyingaccompanyingdocuments,documents,and,and, _______________
to the best of my knowledge and belief, they are true, correct, and complete.Under Penalties of perjury, I declare that I have examined this return and accompanying documents, and,
QuarterSignaturetotoUnderthethePenaltiesbestbestEndedofofof12/31mymyperjury,knowledgeknowledgeIandanddeclarebelief,belief,thattheytheyI haveareareexaminedtrue,true, correct,correct,thisTitlereturnandand complete.complete.and accompanying documents,Date and,
Under Penalties of perjury, I declare that I have examined this return and accompanying documents, and,
SignatureTotaltoUndertothethePenaltiesbestbestCantonofofofIncomemymyperjury,knowledgeknowledgeTaxIandandPaiddeclarebelief,belief,thattheytheyI haveareareexaminedtrue,true,correct,correct,thisTitlereturnandandcomplete.complete.and accompanying documents,Date and,
Signature Title Date
UnderGreatertoSignatureSignatureSignaturethePenaltiesbestofofTaxofmyPerjury,DueknowledgeorIWithhelddeclareandthatbelief,(FromI haveParttheyexaminedare3) true,thiscorrect,returnTitleTitleTitleandandaccompanyingcomplete. documents, and, DateDateDate
Signature Title Date
toBalanceSignatureSignaturethe bestDueof my/knowledgeOverpayment and belief,[TransfertheyCredit]are true, correct, andTitleTitlecomplete. DateDate
SignatureSignature TitleTitle DateDate
Under Penalties of perjury, I declare that I have examined this return and accompanying documents, and,
to the best of my knowledge and belief, they are true, correct, and complete.
