VILLAGE OF LISBON,OHIO RETURN PART 1 - KEEP PART 2 FOR YOUR RECORDS Instructions on Reverse
Form EQR 1-65 Rev. 12-90 EMPLOYER’S QUARTERLY RETURN OF TAX WITHHELD side of Taxpayer’s Copy
DOLLARS CENTS I hereby certify that the information and statements
1. Taxable Earnings paid all Employees subjected to contained herein are true and correct.
Village of Lisbon income tax.
$ (Signed)
2. Actual Tax Withheld in quarter for Village Income Tax $ (Official Title)
3. Adjustment of Tax for prior quarter (see instructions) Date
THIS RETURN MUSTBE FILED
4. Interest: ON OR BEFORE THE DUE DATE SHOWN BELOW
MAKE CHECK OR MONEYORDER PAYABLE TO
5. Penalty VILLAGE OF LISBON INCOME TAX DEPT.
TAX RATE ONE AND ONE HALF PERCENT (1⁄%)12
6. Total $ INCOME TAX DEPT.
P.O. BOX 42
FOR MONTHS OF LISBON,OHIO 44432

DUE ON OR BEFORE
LYLE PRINTING & PUBLISHING CO., SALEM, OH44460
Notify Income Tax Department promptly of any change in ownership or name If receipt is desired, return Taxpayer’s Copy of this W-1
and address shown above. form and enclose self-addressed, stamped envelope.