Division of Taxation 
                                                                                                     50 South Broadway 
                                                                                                     Lebanon, Ohio 45036 
                                                                                                              P: 513-933-7205 
                                                                                                              F: 513-228-3902 

                        20 ____  ANNUAL WITHHOLDING RECONCILIATION 

               Remit this form with corresponding W-2 and 1099 forms on or before February 28  
               Mail to: City of Lebanon Income Tax Department 50 S Broadway Lebanon OH 45036 

FEIN: ____________________ Account # ___________   Submitted By: __________________________________ 
                                                                                                                      Please print 
Employer Name: _______________________________   Official Title: ___________________________________ 

Address: ______________________________________   Signature: _____________________________________ 

           ___________________________________   _________________________________________ 
                                                                      Phone number                                                                  Date 
___ Courtesy Withholding – Please check if reporting tax withheld as a courtesy for employees residing in Lebanon.         

Payment Record 
Please enter withholding payments remitted monthly or quarterly 
January:                April:                                  July:                            October: 

February:               May:                                    August:                          November: 

March:                  June:                                   September:                       December: 

1 stQuarter:            2 ndQuarter:                            3 rdQuarter:                     4 thQuarter: 

                                                                        Total Remitted: 

Reconciliation Summary: 

                                     Total number of W-2 Forms attached 
                                     Total number of 1099 Forms attached 
                                                                        Total Wages 
                             Withholding Tax Obligation (total wages x 1%) 
                                                                        Tax Withheld 
                                                                        Tax Remitted 

                             Overpayment:                                       Tax Due: 

Pursuant to Ordinance Section 152.051 on or before the last day of February of each year, an employer shall file a Withholding 
Reconciliation Return with the Tax Administrator listing the names, addresses and social security numbers of all employees from whose 
qualifying wages tax was withheld or should have been withheld for the Municipality during the preceding calendar year, the amount of tax 
withheld, if any, from each such employee’s qualifying wage, the total amount of qualifying wages paid to such employee during the 
preceding calendar year, the name of every other municipal corporation for which tax was withheld or should have been withheld from 
such employee during the preceding calendar year, any other information required for federal income tax reporting purposes on Internal 
Revenue Service form W-2 or its equivalent form with respect to such employee, and other information as may be required by the Tax 
Administrator.