P - 941 City of Pontiac - Income Tax Division                                                                                                 10 M            2021
            Employer’s Return of Income Tax Withheld                                                                   Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac                              Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments                    Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                                            Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530                             per month ($2.00 minimum)      ____________________________________
                                                                                                                       Interest due 
Signature _______________________________________________________  Date _________________                              (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                                       TOTAL DUE
                                                                                                                       PAY THIS AMOUNT

                                                                                                                       FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                                         TAX YEAR                     2021
                                                                                                                        PAYROLL PERIOD  OCTOBER 10M
                                                                                                                         DUE DATE                     November 30, 2021
                                                                                                                                              
                                                                                                                                            DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                                                 11 M            2021
            Employer’s Return of Income Tax Withheld                                                                   Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac                              Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments                    Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                                            Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530                             per month ($2.00 minimum)      ____________________________________
                                                                                                                       Interest due 
Signature _______________________________________________________  Date _________________                              (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                                       TOTAL DUE
                                                                                                                       PAY THIS AMOUNT

                                                                                                                       FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                                         TAX YEAR                     2021
                                                                                                                        PAYROLL PERIOD  NOVEMBER 11M
                                                                                                                         DUE DATE                     December 31, 2021
                                                                                                                                              
                                                                                                                                            DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                                                 12 M            2021
            Employer’s Return of Income Tax Withheld                                                                   Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac                              Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments                    Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                                            Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530                             per month ($2.00 minimum)      ____________________________________
                                                                                                                       Interest due 
Signature _______________________________________________________  Date _________________                              (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                                       TOTAL DUE
                                                                                                                       PAY THIS AMOUNT

                                                                                                                       FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                                         TAX YEAR                     2021
                                                                                                                        PAYROLL PERIOD  DECEMBER 12M
                                                                                                                         DUE DATE                     January 31, 2022
                                                                                                                                              
                                                                                                                                            DO NOT WRITE BELOW THIS LINE

                                                         CITY OF PONTIAC-INCOME TAX DIVISION
                                              RECONCILIATION OF PONTIAC INCOME TAX WITHHELD                                                     Copies of PW-2s must accompany this document.
2021                            1. TOTAL PONTIAC TAX WITHHELD DURING YEAR AS SHOWN ON FORMS PW-2 OR W-2 ENCLOSED                              $           (A)                                                                                                               2021
PW-3                            2. TOTAL NUMBER OF WITHHOLDING TAX STATEMENTS (FORMS PW-2 OR W-2) TRANSMITTED HEREWITH                                                                                                                                                      PW-3
                                                                                                                        QUARTER ENDED
IMPORTANT                       3. TOTAL PONTIAC TAX WITHHELD AS SHOWN ON FORMS P-941                                   MARCH 31              $                                                                                                                             DUE ON
INFORMATION                                 (use other side if forms P-941 were filed monthly)                          QUARTER ENDED                                                                                                                                       OR 
                                                                                                                        JUNE 30
                               THE NAME ADDRESS AND IDENTIFICATION NUMBER ON THIS FORM MUST BE THE SAME AS USED ON      QUARTER ENDED                                                                                                                                       BEFORE
GROSS PAYROLL                                            FORMS P-941 AND PW-2 OR W-2.  IF NOT CORRECT , PLEASE CORRECT  SEPTEMBER 30                                                                                                                                        2/28/2022
USED TO CALCULATE                                                                       NAME AND ADDRESS                QUARTER ENDED
                                                                                                                        DECEMBER 31
PAYROLL TAX                                                                                                             TOTAL PAYMENTS        $           (B)
                                                                                                                        TO PONTIAC
                                                                                                                        DIFFERENCE            $           (A-B)
$ ____________________________                                                                                          EMPLOYER IDENTIFICATION NO.

                                                                  SIGNATURE                                                      TITLE                                                                             DATE                                              PHONE #

                                                              4.                                                                                                                                 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            2.                                                                                                                         1.
                                                              �                                                                                                                                  Your current address �                                                                                                                                                                                �                                                                                                            �                                                                                                   �                                                                                                   � applicable questions                             Check reason for “Final Return” and answer withheld ___________________________                                            Last pay period on which Pontiac Taxes were
______________________________ ______________________________ Other:                    Zip Code                State                      City                        Street                                         Moved out of Pontiac Zip Code                                   State                      City                              Street                    Name                      Business sold to (Date)                     Wages will be paid starting                   Still operating –                                                  (Date)       Operations will be resumed on          Business temporarily discontinued                                  Business permanently discontinued
                                                                                                                                           ___________________________                                                                                                                                           ___________________________
                                                              _________________________                         __________________________                             _________________________                                                                                      __________________________                                   _________________________ _________________________                  __________________________                                                                                        __________________________
                                                                                        _______________________                                                                                                                            _______________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Ceased paying wages

                                                              4.                                                                                                                                 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            2.                                                                                                                         1.
                                                              �                                                                                                                                  Your current address �                                                                                                                                                                                �                                                                                                            �                                                                                                   �                                                                                                   � applicable questions                             Check reason for “Final Return” and answer withheld ___________________________                                            Last pay period on which Pontiac Taxes were
______________________________ ______________________________ Other:                    Zip Code                State                      City                        Street                                         Moved out of Pontiac Zip Code                                   State                      City                              Street                    Name                      Business sold to (Date)                     Wages will be paid starting                   Still operating –                                                  (Date)       Operations will be resumed on          Business temporarily discontinued                                  Business permanently discontinued
                                                                                                                                           ___________________________                                                                                                                                           ___________________________
                                                              _________________________                         __________________________                             _________________________                                                                                      __________________________                                   _________________________ _________________________                  __________________________                                                                                        __________________________
                                                                                        _______________________                                                                                                                            _______________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Ceased paying wages

                                                              4.                                                                                                                                 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            2.                                                                                                                         1.
                                                              �                                                                                                                                  Your current address �                                                                                                                                                                                �                                                                                                            �                                                                                                   �                                                                                                   � applicable questions                             Check reason for “Final Return” and answer withheld ___________________________                                            Last pay period on which Pontiac Taxes were
______________________________ ______________________________ Other:                    Zip Code                State                      City                        Street                                         Moved out of Pontiac Zip Code                                   State                      City                              Street                    Name                      Business sold to (Date)                     Wages will be paid starting                   Still operating –                                                  (Date)       Operations will be resumed on          Business temporarily discontinued                                  Business permanently discontinued
                                                                                                                                           ___________________________                                                                                                                                           ___________________________
                                                              _________________________                         __________________________                             _________________________                                                                                      __________________________                                   _________________________ _________________________                  __________________________                                                                                        __________________________
                                                                                        _______________________                                                                                                                            _______________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Ceased paying wages

                                                                                                                YEARLY TOTAL $             4TH QUARTER TOTAL $         DECEMBER                  NOVEMBER             OCTOBER                                     3RD QUARTER TOTAL $ SEPTEMBER                                             AUGUST JULY                      2ND QUARTER TOTAL $       JUNE             MAY                        APRIL                                                              1ST QUARTER TOTAL $                                  MARCH                               FEBRUARY                                   JANUARY                                                                                  LIST PAYMENTS MADE WITH P941
                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Eaton Rapids, MI 48827-0530
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              EMPLOYER’S RETURNS
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Income Tax Division
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          SUMMARY                                                                                                                                               P.O. Box 530                    City of Pontiac