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Form W3Q/M                                                                   WITHHOLDING TAX RECONCILIATION RETURN
CITY OF ASHTABULA – INCOME TAX DEPARTMENT                                                          FOR TAX YEAR 2017               Please change tax year if necessary
   4717 MAIN AVE, STE A, ASHTABULA, OHIO 44004                               MUST BE RETURNED WITH W-2’S BY THE END OF FEBRUARY
           VOICE (440) 992-7104
                                                                         8. January...................$ _________________      14. July.........................$ _________________
1. Number of W-2’s attached ..............$_________________             9. February .................$ _________________      15. August ....................$ _________________
2. Number of employees working                                           10. March/Qtr. 1 ...........$ _________________       16. September/Qtr. 3....$ _________________
   in Ashtabula at year end ..................$ _________________        11. April ........................$ _________________ 17. October ..................$ _________________
3. Total payroll for the year ..................$_________________       12. May.........................$ _________________   18. November...............$ _________________
4. Less payroll not subject to tax ........$_________________            13. June/Qtr. 2..............$ _________________      19. December/Qtr. 4.....$ _________________
   Attach explanation                                                    20. Total remitted for year.............................................................................$ _________________
5. Payroll subject to tax .......................$_________________      21. Difference between Lines 6 & 20 (amount due/overpaid) .......................$ _________________
6. Withholding tax liability at                                          Non-resident Employers                                          *Refunds are NOT automatically issued.
   1.8% of Line 5.................................$_________________     Do you withhold tax as a courtesy  Courtesy                     If refund of overpayment is requested
7. Total Ashtabula tax withheld                                          or because the employee(s) work(s)                    Ashtabula please attach explantation. If additional
   per W-2’s .........................................$_________________ in the City of Ashtabula?          Works in                     tax is due, enclose payment with return.

EMPLOYER NAME/ADDRESS                                                        I hereby certify that the information and statements contained herein are
                                                                             true and correct.
                                FID#
                                                                             Signed By _________________________________________________________
                                Email
                                                                             Date ______________________________________________________________
                                Phone
                                                                             Print Name ________________________________________________________
                                                                             Official Title________________________________________________________
                                                                                                            Owner, Partner, Member, President, Treasurer

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GENERAL RECONCILIATION INFORMATION – Form W3Q/M 
On or before the last day of February of each year, every employer must file a withholding reconciliation. copies of all W-2 forms or 
computer listing applicable to the reconciliation must be attached. All information must include the name, address, social security 
number, gross wages, city tax withheld, name of city for which tax was withheld (breakdown for multiple cities, if applicable) and 
any other compensation paid to the individual. Any individual(s) or business entity compensating individuals on a commission or 
contract labor basis must supply copies of the 1099 or appropriate earnings statement on or before the last day of February each 
year. All 1099’s or earnings statements shall include the same type of information as required of the W-2 forms as stated above.

NEW REQUIREMENT: 
Employers having 50 or more employees are Strongly urged to submitted the W2 information on magnetic media. Such filing must 
be submitted in a designated format provided by the city. The employer W2 upload process utilizes the same file format as the 
Social Security Administration (EFW2, formerly MMREF), only with the additional local withholding information included.
if you have any further questions please contact the Income Tax office.

SPECIFIC FILING INFORMATION: 
Form W3/QM must show a breakdown of all withholding payments made either quarterly or monthly. Complete lines 1 through 7. 
The total tax paid should equal 1.8% of Line 1 unless the reduced courtesy withholding rate applies or is included in the total. A 
breakdown and/or explanation is required if applicable.
The completed From W3Q/M and all attachments must be submitted to the City of Ashtabula Income Tax Department, 4717 MAIN 
AVE, STE. A, ASHTABULA, OHIO 44004 on or before February 28 of each year. Retain a copy for your records. Any questions 
regarding completion of these forms, contact the Income Tax Department at (440) 992-7104.