Please change tax year if necessary q     Print Form
FORM W1 1107 EMPLOYER’S WITHHOLDING
                                                                                                                  Tax Year     2017
1. Number of Taxable Employees. . . . . . . . . . . . . . . . . . . . . . . . .                   1  I hereby certify that the information and statements contained here 
2. Total Salaries, Wages, Commissions and other                                                      in and in any schedules or exhibits attached are true and correct.
Compensation paid all employees. . . . . . . . . . . . . . . . . . . . . . . . . 2
                                                                                                     Signed
                                                                                                     Title                                 Date
3. Taxable Earnings (from line 2). . . . . . . . . . . . . . . . . . . . . . . . . . 3               Phone #
4. Actual Tax Withheld at 2.500 %. . . . . . . . . . . . . . . . . . . . . . . . . 4                        THIS RETURN MUST BE FILED ON
5. Adjustments of Tax for Prior Period. . . . . . . . . . . . . . . . . . . . . . 5                         OR BEFORE
6. Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6
7. Penalty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7         MAKE CHECK OR MONEY ORDER TO:
8. Total (Include Interest and Penalty if Due). . . . . . . . . . . . . . . . . 8                           WARREN CITY INCOME TAX
                                                                                                                  P.O. BOX 230
                                                                                                                  WARREN  OH   44482-0230
Name
                                                                                                           Voice  330-841-2551             Fax  330-841-2626
And                                                                                                               Please select period below
                                                                                                     Period Ending
Address
                                                                                                     TAX ID

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