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(12) Employee’s
Social Security Number
(13) Employee’s Name/Address
Check if making any corrections to Employee’s
Name/Address, SSN or Resident PSD
(14) Gross Compensation
Paid This Quarter
(15) Amount of EIT
Withheld This Quarter
(16) Resident
PSD Code
EMPLOYER QUARTERLY RETURN
Local Earned Income Tax Withholding
Make any corrections to EMPLOYER'S NAME & ADDRESS and check here.
DCEDE11REM
*DCEDE11REM*
Location of Business
Year / Quarter
Account #
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 No Change
Do you expect to pay taxable wages next quarter?
Yes No
1. Total Earned Income Tax withheld...........................
2. Credit or adjustment (attach explanation)...............
3. Total of Earned Income Tax due
(line 1 minus line2)...........
4. Total payments made this quarter
(Schedule B)..............................
5. Adjusted total of Earned Income Tax due
(line 3 minus line 4).........
6. Interest ( 0.246% per month (or a fraction of) if paid
after the due date x line 5)......................................
7. Late Filing Fee.......................................................
8. Balance due with Return (add lines 5+6+7) .................
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M M D D Y Y Y Y
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PAGE 1 OF 1
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 calling Berkheimer at
610-599-3182. Or, you can visit our website at www.hab-inc.com.
Berkheimer is not the appointed tax hearing officer for your taxing district and will not
accept any petitions for appeal. Petitions for appeal must be filed with the appropriate
appeals board for your County. Berkheimer can provide you with the proper procedures
and forms necessary to file an appeal with the appeals board for your Tax Collection
District.
PO Box 25132
Lehigh Valley, PA 18002-5132
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(17) First Page Total .....................................................
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Total Amount Enclosed..... $
9. Date period ended (MM/DD/YYYY)............
10.. Total pages of this Return ...........................
11. Total number of employees listed ...................
Employer PSD Code Federal EIN or Social Security # Account Number Year Quarter
Municipal Taxing Authority (City, Borough, or Township) in Which Facility or Business is Located (Attach listing of multiple locations within PA if applicable)
County Business Phone Number (if above is incorrect) Business Fax Number
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Primary Contact Individual (First Name, Last Name)
Signature of Primary Contact Individual Date (MM/DD/YYYY)
Title
Primary Contact Phone Number
Primary Contact Email Address
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
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Make checks payable to: HAB-EIT
There will be a $29.00 fee for returned payments.
There will be an additional fee assessed if no payment is enclosed for tax due at time of filing.
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