CLGS-32-3 (1-13)
                                                     QUARTERLY ESTIMATED
                             Local Earned Income Tax Withholding
         You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes. Contact your Tax Officer.             

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CLGS-32-3 (1-13)                                                  1st QUARTER ESTIMATED Local Earned Income Tax 
                                                                                             If you moved, enter the effective date: ____/____/______
                                                                                             Check here if address change also applies to spouse 
                                                                                              Make any corrections to NAME, STREET ADDRESS or
                                                                                              RESIDENT MUNICIPALITY and check here.  
                                                                                              INCLUDE INFO IF NOT SHOWN.
                                                               1. Earned Incomeand/or net profits                                  .00 
                                                               (must enter amount)January 1 thru March 31                           . . .
                                                                                                                                   .00 
  Resident PSD CodeWork Location PSD Code2. Tax Rate of _________ multiplied by line 1 . . . . . . . .
                                                                                                                                   .00 
                                                               3. Employer Withheld (January 1 thru March 31 Only)  . .
                                                                                                                                   .00 
Resident Municipality:_______________________________________  4. TAX DUE:(line 2 minus line 3) . . . . . . . . . . . . . . . . . .
                                                               5. Penalty and Interest: Line 4 multiplied by.00 
If you have no earned income, state the reason: retired/homemaker/______ per month if paid after the due date  . . . . . . .
student/disabled/temporarily unemployed/minor (state age)/other6.TOTAL PAYMENT DUE(add lines 4 & 5) . . . . . . . . .              .00 
(please specify)
❑ Check here if ALL tax is withheld by employer(s). Payable to: ________________________________
Do not complete information requested on Lines 1 thru 6. 
                                                                                        Social Security Number
                                                     DO NOT WRITE BELOW THIS LINE

CLGS-32-3 (1-13)                                                  2nd QUARTER ESTIMATED Local Earned Income Tax 
                                                                                             If you moved, enter the effective date: ____/____/______
                                                                                             Check here if address change also applies to spouse 
                                                                                              Make any corrections to NAME, STREET ADDRESS or
                                                                                              RESIDENT MUNICIPALITY and check here.  
                                                                                              INCLUDE INFO IF NOT SHOWN.
                                                               1. Earned Incomeand/or net profits                                  .00 
                                                               (must enter amount)April 1 thru June 30 . . . . . . . .
                                                                                                                                   .00 
  Resident PSD CodeWork Location PSD Code2. Tax Rate of _________ multiplied by line 1 . . . . . . . .
                                                                                                                                   .00 
                                                               3. Employer Withheld (April 1 thru June 30 Only) . . . . . .
                                                                                                                                   .00 
Resident Municipality:_______________________________________  4. TAX DUE:(line 2 minus line 3) . . . . . . . . . . . . . . . . . .
                                                               5. Penalty and Interest: Line 4 multiplied by.00 
If you have no earned income, state the reason: retired/homemaker/______ per month if paid after the due date  . . . . . . .
student/disabled/temporarily unemployed/minor (state age)/other6.TOTAL PAYMENT DUE(add lines 4 & 5) . . . . . . . . .              .00 
(please specify)
❑ Check here if ALL tax is withheld by employer(s). Payable to: ________________________________
Do not complete information requested on Lines 1 thru 6. 
                                                                                        Social Security Number
                                                     DO NOT WRITE BELOW THIS LINE
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CLGS-32-3 (1-13)                                                  3rd QUARTER ESTIMATED Local Earned Income Tax 
                                                                                             If you moved, enter the effective date: ____/____/______
                                                                                             Check here if address change also applies to spouse 
                                                                                              Make any corrections to NAME, STREET ADDRESS or
                                                                                              RESIDENT MUNICIPALITY and check here.  
                                                                                              INCLUDE INFO IF NOT SHOWN.
                                                               1. Earned Incomeand/or net profits                                  .00 
                                                               (must enter amount)July 1 thru September 30  . . .
                                                                                                                                   .00 
  Resident PSD CodeWork Location PSD Code2. Tax Rate of _________ multiplied by line 1 . . . . . . . .
                                                                                                                                   .00 
                                                               3. Employer Withheld (July 1 thru September 30 Only)  . .
                                                                                                                                   .00 
Resident Municipality:_______________________________________  4. TAX DUE:(line 2 minus line 3) . . . . . . . . . . . . . . . . . .
                                                               5. Penalty and Interest: Line 4 multiplied by.00 
If you have no earned income, state the reason: retired/homemaker/______ per month if paid after the due date  . . . . . . .
student/disabled/temporarily unemployed/minor (state age)/other6.TOTAL PAYMENT DUE(add lines 4 & 5) . . . . . . . . .              .00 
(please specify)
❑ Check here if ALL tax is withheld by employer(s). Payable to: ________________________________
Do not complete information requested on Lines 1 thru 6. 
                                                                                        Social Security Number
                                                     DO NOT WRITE BELOW THIS LINE
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CLGS-32-3 (1-13)                                                  4th QUARTER ESTIMATED Local Earned Income Tax 
                                                                                             If you moved, enter the effective date: ____/____/______
                                                                                             Check here if address change also applies to spouse 
                                                                                              Make any corrections to NAME, STREET ADDRESS or
                                                                                              RESIDENT MUNICIPALITY and check here.  
                                                                                              INCLUDE INFO IF NOT SHOWN.
                                                               1. Earned Incomeand/or net profits                                  .00 
                                                               (must enter amount)October 1 thru December 31 . .
                                                                                                                                   .00 
  Resident PSD CodeWork Location PSD Code2. Tax Rate of _________ multiplied by line 1 . . . . . . . .
                                                                                                                                   .00 
                                                               3. Employer Withheld (October 1 thru December 31 Only)  .
                                                                                                                                   .00 
Resident Municipality:_______________________________________  4. TAX DUE:(line 2 minus line 3) . . . . . . . . . . . . . . . . . .
                                                               5. Penalty and Interest: Line 4 multiplied by.00 
If you have no earned income, state the reason: retired/homemaker/______ per month if paid after the due date  . . . . . . .
student/disabled/temporarily unemployed/minor (state age)/other6.TOTAL PAYMENT DUE(add lines 4 & 5) . . . . . . . . .              .00 
(please specify)
❑ Check here if ALL tax is withheld by employer(s). Payable to: ________________________________
Do not complete information requested on Lines 1 thru 6. 
                                                                                        Social Security Number
                                                     DO NOT WRITE BELOW THIS LINE