Instructions Employer Withholding Registration 
                                                     
     Each employer withholding City of Jackson Income Tax from employee’s wages should register 
     with the Income Tax Office.  For the convenience of the employer, the Federal Identification 
     Number assigned to the employer by the Federal District Director of Internal Revenue will be used 
     for the City of Jackson Income Tax Office records. 
      
     Please fill out and send to Lisa Skalski at lskalski@cityofjackson.org                               Submit by Email
                                                     
S-SS-4     City of Jackson – Income Tax Office                 Employer’s Federal Identification Number 
                Employer’s Withholding Registration 
 
 1.  TRADE NAME: 

 2.  OWNER’S NAME:  (IF DIFFERENT FROM TRADE NAME) 

 3.  MAIN OFFICE MAILING ADDRESS: 

 4.  JACKSON ADDRESS: 

(CHECK TYPE OF ORGANIZATION)                                                                              LOCAL TELEPHONE NO. 
                                                                                                           
 5.                SOLE PROPRIETOR             PARTNERSHIP              CORPORATION              OTHER 6. 
NO. OF EMPLOYEES             ACCOUNTING PERIOD 
                              
7.                           8.             CALENDAR YEAR          FISCAL YEAR ENDING ------------ 
                              
IF THIS BUSINESS WAS PREVIOUSLY OWNED BY ANOTHER     GIVE THE DATE THE BUSINESS WAS ACQUIRED BY CURRENT 
EMPLOYER PRINT NAME BELOW.                           EMPLOYER. 
                                                      
9.                                                   10. 
(PAYMENT FREQUENCY)                                  (FOR INTERNAL USE ONLY) 
                                                     P I N: 
11.    MONTHLY               QUARTERLY   
           SIGNATURE                                        TITLE                                                        DATE 

     May, 2018