VILLAGE OF LISBON, OHIO VILLAGE OF LISBON, OHIO
INCOME TAX DEPARTMENT RECONCILIATION OF VILLAGE OF LISBON INCOME
P.O. BOX 42 TAX WITHHELD FROM WAGES
LISBON, OHIO 44432-0042
3. Total VILLAGE OF LISBON Income Tax Withheld during              , for:
(Form EQR)
1. Total number of employees as represented by Quarter ended March 31, $
Forms W-2 submitted herewith . . . . . . . . . . . . . . . . . . . . Quarter ended June 30, $
Quarter ended September 30, $
2. Total  VILLAGE OF LISBON Income Tax withheld from wages
Quarter ended December 31, $
during                        as shown by employer’s statement
4. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
(Form W-2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  $
5. Difference between Lines 2 & 4  . . . . . . . . . . . . . . . . . .$

*If Line 5 indicates a balance due, the amount thereof should accompany this
return; If Line 5 indicates an overpayment, a refund request signed by the
employer should be made.
W-3
1M 6-03 LYLE PRINTING & PUBLISHING CO., SALEM, OH 337-3419

                               INSTRUCTIONS
The Original of this reconciliation form must be filed with the address and Lisbon Income Tax Withholding account number
VILLAGE OF LISBON, P.O. Box 42, LISBON, OH 44432                of employer.  An adding machine tape, or some other type of
on or before January 31,                                        list, listing the amount of Lisbon income tax withheld, as
unless a written request for extension has been made to and     indicated by individual employee’s statements, should be
granted by City Income  Tax Office.   This form must be         attached thereto.  A legible copy of commercially printed W-
accompanied by copies of employee’s statements (Form W-2)       2 Forms will be accepted by this office without specific
showing: 1) name and address of employer; 2) social securi-     approval, if the forms have been approved by the Internal
ty number; 3) gross earnings paid before any payroll deduc-     Revenue Service and contain the required information for
tions; 4) amount of income tax withheld; and 5) name,           Lisbon income tax purposes.

If the difference between lines 2 and 4 indicates a balance due, the amount thereof should accompany this return; if the difference indicates an over-
payment, attach an explanation.

                               INSTRUCTIONS
The Original of this reconciliation form must be filed with the address and Lisbon Income Tax Withholding account number
VILLAGE OF LISBON, P.O. Box 42, LISBON, OH 44432                of employer.  An adding machine tape, or some other type of
on or before January 31,                                        list, listing the amount of Lisbon income tax withheld, as
unless a written request for extension has been made to and     indicated by individual employee’s statements, should be
granted by City Income  Tax Office.   This form must be         attached thereto.  A legible copy of commercially printed W-
accompanied by copies of employee’s statements (Form W-2)       2 Forms will be accepted by this office without specific
showing: 1) name and address of employer; 2) social securi-     approval, if the forms have been approved by the Internal
ty number; 3) gross earnings paid before any payroll deduc-     Revenue Service and contain the required information for
tions; 4) amount of income tax withheld; and 5) name,           Lisbon income tax purposes.

If the difference between lines 2 and 4 indicates a balance due, the amount thereof should accompany this return; if the difference indicates an over-
payment, attach an explanation.