Employer Quarterly Return Earned Income Tax Withholding 2023-2026

CLGS-32-5 10-22 EMPLOYER QUARTERLY RETURN Local Earned Income Tax Withholding Keystone Collections Group PO Box 559 Irwin PA 15642-0559 You are entitled to receive a written explanation of your rights with regard to the audit appeal enforcement refund and collection of local taxes by contacting your Tax Officer. Check if making any corrections to EMPLOYER S Name Address File ONLINE at Business. KeystoneCollects. com EMPLOYER BusINEss NAME use federal ID Name sECOND LINE Of ADDREss CITY OR POsT OffICE sTATE zIP WORKPLACE LOCATION city Borough township enter physical address of workplace facility COuNTY BusINEss PHONE NuMBER EMPLOYER PsD CODE fEDERAL EIN OR sOCIAL sECuRITY BusINEss fAx NuMBER ACCOuNT NuMBER YEAR AND QuARTER INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS No PO Boxes 1. Total Earned Income Tax Withheld. 8. Date Period Ended MMDDYYYY. 3. Total of Earned Income Tax Due line 1 minus line 2. 10. Total Number of Employees Listed. 2. Credit or Adjustment attach detail. 4. Total Payments Made this Quarter. 5. Adjusted Total of EIT Due line 3 minus line 4. 7. Balance Due with Return Add lines 5 and 6. 6. Penalty Interest due date x line 5 per month after. 9. Total Pages of This Return. If there has been a change of ownership or other transfer of business during the quarter attach explanation and give name of present owner and date the change took place. CHANGE Do you expect to pay taxable wages next quarter Yes No 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 sIGNATuRE Of PRIMARY CONTACT INDIvIDuAL DATE MM/DD/YYYY 11 EMPLOYEE S SOCIAL SECURITY NUMBER 13 GROSS COMPENSATION PAID THIS QUARTER 12 EMPLOYEE S NAME/ADDRESS Check box if making any corrections to EMPLOYEE S Name/Address SSN or Resident PSD 16 FIRST PAGE TOTAL. Make check payable to KEYSTONE COLLECTIONS GROUP There will be a 29 bank fee for returned payments and checks. 14 AMOUNT OF EIT WITHHELD THIS QUARTER TOTAL Amount Enclosed. 15 RESIDENT PSD CODE Employer federal EIN Year and Quarter 16 THIS PAGE TOTAL. Check if making any corrections to EMPLOYER S Name Address File ONLINE at Business. KeystoneCollects. com EMPLOYER BusINEss NAME use federal ID Name sECOND LINE Of ADDREss CITY OR POsT OffICE sTATE zIP WORKPLACE LOCATION city Borough township enter physical address of workplace facility COuNTY BusINEss PHONE NuMBER EMPLOYER PsD CODE fEDERAL EIN OR sOCIAL sECuRITY BusINEss fAx NuMBER ACCOuNT NuMBER YEAR AND QuARTER INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS No PO Boxes 1. com EMPLOYER BusINEss NAME use federal ID Name sECOND LINE Of ADDREss CITY OR POsT OffICE sTATE zIP WORKPLACE LOCATION city Borough township enter physical address of workplace facility COuNTY BusINEss PHONE NuMBER EMPLOYER PsD CODE fEDERAL EIN OR sOCIAL sECuRITY BusINEss fAx NuMBER ACCOuNT NuMBER YEAR AND QuARTER INCLUDE ONLY W-2 WAGE EARNERS FROM BUSINESS PAYROLL - USE EMPLOYEE STREET ADDRESS No PO Boxes 1. Total Earned Income Tax Withheld. 8. Date Period Ended MMDDYYYY. 3. Total of Earned Income Tax Due line 1 minus line 2.