FORM N5-2022                                                                           EMPLOYER’S WITHHOLDING RETURNS 
 NORWOOD RECONCILIATION OF TAX WITHHELD FOR                      2022 
 NORWOOD TAX OFFICE                                               5. WITHHOLDING  TAX  LIABILITY  OF  2%  OF  LINE 4......... 
 4645 MONTGOMERY ROAD                                             6. TOTAL INCOME TAX WITHHELD FROM WAGES AND PAID TO 
                                                                      CITY OF NORWOOD DURING 2022 
 NORWOOD, OH 45212                                                    QUARTER ENDING MARCH 31                $........ 
 PHONE 513 458- 4590                                                  QUARTER ENDING JUNE 30                  $........ 
 1. TOTAL NUMBER OF TAXABLE EMPLOYEES...                              QUARTER ENDING SEPTEMBER 30            $....... 
 2. TOTAL PAYROLL FOR THE YEAR. ......................   $            QUARTER ENDING DECEMBER 31              $......... 
 3. LESS PAYROLL NOT SUBJECT TO TAX ............   $             
 4. PAYROLL SUBJECT TO TAX ................................   $   
                                                                  
                                                                      TOTAL FOR YEAR                         $....... 
 ACCOUNT NO:                                                      
                                                                  7. OVERPAYMENT        $.........OR         TAX  DUE $....... 
                                                                      (SUBTRACT TOTAL OF LINE 6 FROM LINE 5) 
                                                                                        THIS FORM MUST BE FILED ON OR BEFORE 
                                                                                        FEBRUARY 28, 2023 ATTACH COPIES OF 
                                                                                   W-2 FORMS AND INCLUDE 1099 MISC FORMS 

                                                                      TAX[USEOFFICEONLY                                        ] 
 
 DO NOT SEND THE RECONCILIATION TO: NORWOOD P.O. BOX 640332 
 THIS LOCK BOX IS ONLY FOR QUARTERLY OR MONTHLY PAYMENTS 

                          REMIT THIS RECONCILIATION FORM & W-2 FORMS TO: 

                                                                NORWOOD TAX OFFICE 
                                                                4645 MONTGOMERY ROAD 
                                                                NORWOOD, OH 45212 

                                                                RECONCILIATION INSTRUCTIONS 

 Original of this reconciliation form must be filed with the Tax Commissioner of Norwood, OH on or before 
 February 28, 2023 together with copies of W-2 Forms or a list of employees withheld from as requested under 
 line No. 7. List must include employee's name, address, Social Security Number, taxable earnings, and 
 amount of Norwood earnings tax withheld. Make a copy of this form for your records. 
 

 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 

   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O Box 640332                                                     COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 JANUARY 2023 
                                                                    DUE ON OR BEFORE:                     FEBRUARY 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
 
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 FEBRUARY 2023 
                                                                    DUE ON OR BEFORE:                     MARCH 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 MARCH 2023 
                                                                    DUE ON OR BEFORE:                     APRIL 15, 2023 

                                                                   (SIGNED)                                                    
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 

 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 

   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 APRIL 2023 
                                                                    DUE ON OR BEFORE:                     MAY 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 MAY 2023 
                                                                    DUE ON OR BEFORE:                     JUNE 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                     DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER               
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-             
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                    
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                        
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                        AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 JUNE 2023 
                                                                    DUE ON OR BEFORE:                     JULY 15, 2023 

                                                                   (SIGNED)                                                    
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 

 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 

   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                                  DOLLARS           CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER                            
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-                          
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                                      →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3)         ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                                     
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE” AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                        JULY 2023 
                                                                    DUE ON OR BEFORE:                            AUGUST 15, 2023 
 
                                                                   (SIGNED)                                                                  
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                               
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
 
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                                  DOLLARS           CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER                            
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-                          
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                                      →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3)         ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                                     
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE” AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                        AUGUST 2023 
                                                                    DUE ON OR BEFORE:                            SEPTEMBER 15, 2023 
 
                                                                   (SIGNED)                                                                  
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                               
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                                  DOLLARS           CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER                            
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-                          
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                                      →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3)         ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                                     
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE” AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                        SEPTEMBER 2023 
                                                                    DUE ON OR BEFORE:                            OCTOBER 15, 2023 

                                                                   (SIGNED)                                                                  
                                                                       PRINTED 
                                                                   ( NAME    )                                                               
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 

 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 

   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                   DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER             
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-           
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                      
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                      AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 OCTOBER 2023 
                                                                    DUE ON OR BEFORE:                     NOVEMBER 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                   DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER             
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-           
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                      
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                      AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 NOVEMBER 2023 
                                                                    DUE ON OR BEFORE:                     DECEMBER 15, 2023 
 
                                                                   (SIGNED)                                                    
 
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT. 
 
 EMPLOYER’S MONTHLY  RETURN OF TAX WITHHELD 
                              
   CITY OF NORWOOD            MAKE CHECK PAYABLE TO:                   NUMBER OF TAXABLE EMPLOYEES →                   DOLLARS  CENTS 
   EARNINGS TAX DEPT.                                              2. TOTAL SALARIES, WAGES, COMMISSIONS, AND OTHER             
   P.O. Box 640332                                                    COMPENSATION PAID ALL EMPLOYEES (*) ⎯⎯→ 
                                                                  
   CINCINNATI, OH 45264-0332                                       3. LESS: NON-TAXABLE ITEMS (COMPENSATION PAID NON-           
                              MAILING LABELS                           RESIDENTS FOR SERVICES OUTSIDE NORWOOD) 
                              PROVIDED                                                                       →                  
   PHONE 513-458-4590         MAKE COPIES FOR                      4. TAXABLE EARNINGS (ITEM 2 MINUS ITEM 3) ⎯→ 
   FAX 513-458-4581           YOUR RECORDS                                                                                      
                                                                   5. ACTUAL TAX WITHHELD AT 2.0%⎯⎯⎯⎯⎯→ 
                                                                   
   ACCOUNT NO:                                                     (*) IF NO WAGES PAID THIS QUARTER MARK “NONE”                      AND RETURN THIS FORM WITH  EXPLANATION 
                    NOTIFY INCOME TAX DEPARTMENT PROMPTLY OF ANY 
                    CHANGES IN OWNERSHIP OR NAME AND ADDRESS           FOR THE MONTHS OF:                 DECEMBER 2023 
                                                                    DUE ON OR BEFORE:                     JANUARY 15, 2024 

                                                                   (SIGNED)                                                    
                                                                       PRINTED 
                                                                   ( NAME    )                                                 
                                                                                   I HEREBY CERTIFY THAT THE INFORMATION AND 
                                                                                   STATEMENTS CONTAINED ARE TRUE AND CORRECT.