Form Eqr - Employer'S Quarterly Return Of Tax Withheld - Village Of Mantua

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VILLAGE OF MANTUA, O.
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Form EQR
EMPLOYER'S QUARTERLY RETURN OF TAX WITHHELD
Employer's Name:______________________________________
Federal ID Number: ____________________________________
Address:______________________________________________
City/State/Zip:_________________________________________
.
Number of Taxable Employees: ___________
Dollars
Cents
1.
Total Salaries, Wages, Commissions and other Compensation
$
2.
___________
.___________
Paid all employees (*)
Less: Non-taxable Items (Compensation paid non-residents for
$
3.
___________
.___________
Services outside Mantua)
$
Taxable Earnings (Item 2 minus Item 3)
4.
___________
.___________
$
Actual Tax Withheld in Quarter for Village Income Tax
5.
___________
.___________
$
Adjustment of Tax for Prior Quarter (see instructions)
5a.
___________
.___________
$
Interest (1/2% per month or fraction thereof)
6.
___________
.___________
$
Penalty (3% per month or fraction thereof)
7.
___________
.___________
.
.
$
8. TOTAL (Include interest and penalty, if due)
________
.________
* If no wages paid this quarter, mark "None" and return this form with explanation.
I hereby certify that the information and statements contained herein and in any schedules or
exhibits attached are true and correct.
(Signed) ____________________________
Date _________________________
(Official Title) _______________________
Owner, Partner, Member, President, Treasurer, Agent
MAKE CHECK OR MONEY ORDER PAYABLE TO:
VILLAGE OF MANTUA, O. - INCOME TAX
TAX RATE:
ONE AND ONE-HALF PERCENT (1 1/2%)
FOR MONTHS OF _______________________
Mail to: INCOME TAX DEPT.
P.O. Box 775
DUE ON OR BEFORE_____________________
MANTUA, OH 44255
Notify Income Tax Dept. promptly of any change in
If receipt is desired, enclose
ownership or name and address shown above.
self-addressed, stamped envelope.

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