Employer'S Annual Reconciliation On Earned Income Tax Withheld
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1SM
546 Wendel Road
Irwin, PA 15642
724-978-0300 fax 724-978-0339
MUNICIPALITY: __________________________________________________________________
EMPLOYER’S ANNUAL RECONCILIATION ON EARNED INCOME TAX WITHHELD
Due by February 28
Tax Year ________
Employer’s Name and Address:
Federal ID Number:
1. Total number of W-2 statements accompanying this report
_____________
2. Total tax withheld as shown on W-2 statements attached
_____________
3. Total quarterly tax withheld as reported on employer’s quarterly returns
st
1
Quarter ending March 31
______________
nd
2
Quarter ending June 30
______________
rd
3
Quarter ending September 30
______________
th
4
Quarter ending December 31
______________
TOTAL REMITTED
_____________
4. Any difference between lines 2 and 3 must be fully explained in attached statement.
I hereby certify that this has been examined by me and the information herein is true, correct and complete.
Signature_______________________________________________ Date___________________________
INSTRUCTIONS
1.
Include employer’s full name and address.
6.
Please issue any additional monies owed when
2.
List Federal ID number.
filing reconciliation.
3. Reconciliation should be filed on or before
7.
If an employers total payroll consists of a number
February 28. This form should be accompanied by
of separate units or establishments, the attached W-
a copy or facsimile of the W-2 form for each
2 forms should be assembled accordingly and a
employee from whom earned income tax has been
separate reconciliation should be submitted.
withheld during the above-mentioned period.
8.
Please remit all applicable documentation to
4.
The total of earned income tax withheld, as
Keystone Collections Group, 546 Wendel Road,
reflected on W-2, should be entered on line 2.
Irwin, PA 15642.
5.
Earned income tax as reported on a quarterly basis
should be entered on line 3.
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