CLGS-32-5 (06-13)
EMPLOYER QUARTERLY RETURN
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.
EMPLOYER BUSINESS NAME (Use Federal ID Name)
EMPLOYER BUSINESS LOCATION - STREET ADDRESS (PONoBox, RD or RR)
SECOND LINE OF ADDRESS
CITY STATE ZIP
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MUNICIPAL TAXING AUTHORITY (City, Borough, Township) IN WHICH FACILITY OR BUSINESS IS LOCATED(Attach listing of multiple locations within PA if applicable)
COUNTY BUSINESS PHONE NUMBER BUSINESS FAX NUMBER
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EMPLOYER PSD CODE FEDERAL EIN OR SOCIAL SECURITY # ACCOUNT NUMBER YEAR AND QUARTER
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1. Total Earned Income Tax Withheld . . . . . . . . . . . . $ 8. Date Period Ended (MM/DD/YYYY). . . . . . . . . . . .
2. Credit or Adjustment(attach explanation) . . . . . . . . . $ 9. Total Pages of This Return . . . . . . . . . . . . . . . . . .
3. Total of Earned Income Tax Due(line 1 minus line 2) .$ 10. Total Number of Employees Listed . . . . . . . . . . .
4. Total Payments Made this Quarter . . . . . . . . . . . . . $ If there has been a change of ownership or other transfer of business during
5. Adjusted Total of EIT Due(line 3 minus line 4) . . . . . . $ the quarter, attach explanation and give name of present owner and date the
change took place. CHANGE NO CHANGE
6. Penalty & Interest ( ___%dueper monthdate xafterline 5 ) $ □ □
Do you expect to pay taxable wages next quarter? Yes No
7.Balance Due with Return (Add lines 5 and 6) . . . . $ □ □
Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying
schedules and statements and to the best of my (our) belief, they are true, correct and complete.
PRIMARY CONTACT INDIVIDUAL (First Name, Last Name)
TITLE
PRIMARY CONTACT PHONE NUMBER PRIMARY CONTACT EMAIL ADDRESS
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SIGNATURE OF PRIMARY CONTACT INDIVIDUAL DATE (MM/DD/YYYY)
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(11)EMPLOYEE’S SOCIAL SECURITY NUMBER(12)EMPLOYEE’S NAME/ADDRESS COMPENSATIONTHIS QUARTER(13)GROSS (14)AMOUNT OF EITPAID WITHHELD THISQUARTER (15)RESIDENTPSD CODE
$ $
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$ $
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$ $
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$ $
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(16) FIRST PAGE TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $
ThereMake Checkswill be apayable$_______to: __________________________fee for returned payments & checks. TOTAL Amount Enclosed . . . . . . . $
NOT to be filed with the PA Department of Revenue. Please file with your local EIT Collector.