Tax Year                                  VILLAGE OF EVENDALE
FORM W3 12                                10500 READING RD
 EMPLOYER'S                               EVENDALE  OH   45241-2574
 WITHHOLDING
 RECONCILIATION
                     Voice  513-563-2671                 Fax  513-563-4636

            DUE DATE 02/28/

                                                                   FEDERAL ID NUMBER
Name
                                                                   NAME OF PERSON
And                                                                COMPLETING FORM
                                                                   LOCAL PHONE NUMBER
Address
                                                                   NUMBER OF EMPLOYEES LISTED

                     EMPLOYEE W2'S MUST ACCOMPANY THIS FORM
                                            INSTRUCTIONS
1. Attach check payable to VILLAGE OF EVENDALE,  for difference if withholding exceeds remittance.
2. If remittance exceeds amount withheld, give explanation and request refund below.
3. Attach explanation if column 2 is used.
4. IF NONEMPLOYEE COMPENSATION WAS PAID IN EXCESS OF $600.00 PER INDIVIDUAL, COPIES OF FORM 1099
MUST ACCOMPANY THIS RETURN.
ENTER PAYROLL BY QUARTERLY OR MONTHLY TOTALS
                     (1)                    (2)              (3)                    (4)           (5)
                     Gross                Payroll Not     Payroll                   Tax           Tax Paid
Period               Payroll              Subject to Tax Subject to Tax             Due           Per Your Records

January

February

March/Qtr-1

April

May

June/Qtr-2

July

August

September/Qtr-3

October

November

December/Qtr-4

TOTALS

                                                                   TOTAL REMITTANCE MADE

Employer - Explain any differences:                                                 DIFFERENCE