HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK        CITY OF HAMTRAMCK
     IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO
     QUESTIONS ON THE REVERSE SIDE                         H941-501                                         Withholding Payment
                                                                    AMOUNT WITHHELD 1                           P.O. BOX 209
                                                                    1ST MONTH THIS QTR              EATON RAPIDS, MI 48827-0209
1                  SIGNATURE                          PHONE #       AMOUNT WITHHELD 2
                                                                                                    VALIDATION AREA BELOW
                                                                    2ND MONTH THIS QTR
             TITLE                                    DATE          AMOUNT WITHHELD 3
                                                                    3RD MONTH THIS QTR
2023                                                                TOTAL TAX WITHHELD 4
                                                                    THIS QUARTER
                                                                                       5
                                                                    ADJUSTMENT
                                                                    ADJUSTED TAX       6
                                                                    WITHHELD
     PERIOD              DUE ON               IDENTIFICATION NO.    AMOUNT             7
     1-1-23 to 3-31-23   4-30-23                                    DUE

     HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK        CITY OF HAMTRAMCK
     IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO
     QUESTIONS ON THE REVERSE SIDE                         H941-501                                         Withholding Payment
                                                                    AMOUNT WITHHELD 1                           P.O. BOX 209
                                                                    1ST MONTH THIS QTR              EATON RAPIDS, MI 48827-0209
2                  SIGNATURE                          PHONE #       AMOUNT WITHHELD 2
                                                                                                    VALIDATION AREA BELOW
                                                                    2ND MONTH THIS QTR
             TITLE                                    DATE          AMOUNT WITHHELD 3
                                                                    3RD MONTH THIS QTR
                                                                    TOTAL TAX WITHHELD 4
2023                                                                THIS QUARTER
                                                                                       5
                                                                    ADJUSTMENT
                                                                    ADJUSTED TAX       6
                                                                    WITHHELD
     PERIOD              DUE ON               IDENTIFICATION NO.    AMOUNT             7
     4-1-23 to 6-30-23   7-31-23                                    DUE

     HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK        CITY OF HAMTRAMCK
     QUESTIONS ON THE REVERSE SIDE                         H941-501
     IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO           Withholding Payment
                                                                    AMOUNT WITHHELD 1                           P.O. BOX 209
                                                                    1ST MONTH THIS QTR              EATON RAPIDS, MI 48827-0209
3                  SIGNATURE                          PHONE #       AMOUNT WITHHELD 2
                                                                                                    VALIDATION AREA BELOW
                                                                    2ND MONTH THIS QTR
             TITLE                                    DATE          AMOUNT WITHHELD 3
                                                                    3RD MONTH THIS QTR
                                                                    TOTAL TAX WITHHELD 4
2023                                                                THIS QUARTER
                                                                                       5
                                                                    ADJUSTMENT
                                                                    ADJUSTED TAX       6
                                                                    WITHHELD
     PERIOD              DUE ON               IDENTIFICATION NO.    AMOUNT             7
     7-1-23 to 9-30-23   10-31-23                                   DUE

     HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK        CITY OF HAMTRAMCK
     IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO
     QUESTIONS ON THE REVERSE SIDE                         H941-501                                         Withholding Payment
                                                                    AMOUNT WITHHELD 1                           P.O. BOX 209
                                                                    1ST MONTH THIS QTR              EATON RAPIDS, MI 48827-0209
4                  SIGNATURE                          PHONE #       AMOUNT WITHHELD 2
                                                                                                    VALIDATION AREA BELOW
                                                                    2ND MONTH THIS QTR
             TITLE                                    DATE          AMOUNT WITHHELD 3
                                                                    3RD MONTH THIS QTR
                                                                    TOTAL TAX WITHHELD 4
2023                                                                THIS QUARTER
                                                                                       5
                                                                    ADJUSTMENT
                                                                    ADJUSTED TAX       6
                                                                    WITHHELD
     PERIOD              DUE ON               IDENTIFICATION NO.    AMOUNT             7
     10-1-23 to 12-31-23 1-31-24                                    DUE

     CITY OF HAMTRAMCK–ANNUAL RECONCILIATION • INCOME TAX WITHHELD                                             HW-3
DUE ON OR BEFORE                   IDENTIFICATION NO.               RETURN WITH FORMS              TAX WITHHELD
     2-28-24                                                        W-2 TO                         AS SHOWN ON
                                                                    CITY OF HAMTRAMCK              ATTACHED W2’S
                                                                    WITHHOLDING PAYMENT            1
                                                                    P.O BOX 209
                                                                    EATON RAPIDS, MI 48827-0209     TAX PAID
                                                                                                   TOTALS FROM
                                                                    NUMBER OF                      REVERSE SIDE
                                                                    W-2’S SUBMITTED                2
                                                                                                    BALANCE
2023                                                                                                DUE
                                                                                                    PAY IN FULL
                                                                                                   THIS RETURN
                 SIGNATURE                            PHONE #                                      3
                                                                                                   OVERPAYMENT
             TITLE                                    DATE                                          ATTACH
                                                                                                   EXPLANATION
                                                                                                   4

                                                                                                                                                                     4.                                                                                                                                                                          3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         2.                                                                                                                                                       1. 
                                                                                                                                                                                                                                                                                                                                                 Your current address:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              applicable questions:                   Check reason for “Final Return” and answer                                 were withheld _______________________                                         Last pay period on which Hamtramck taxes
                                                                                                                                                                      Other:                                                  City                                                       Street                                                                                                                                              Moved out of Hamtramck                                City                                                    Street                                               Name                                                                                          Business sold to:                       (Date)___________________________                       Wages will be paid starting                                        Still operating - Ceased paying wages.                                                                       (Date)___________________________                       Operations will be resumed on                                   Business temporarily discontinued                                   Business permanently discontinued 
________________________________                                 ________________________________
                                                                                                                                                                                                                              ____________________________                                                                                                                                                                                                                                         ____________________________
                                                                                                                                                                     __________________________                                                                                          __________________________                                                                                                                                                                                                                                        __________________________                           __________________________

                                                                                                                                                                     4.                                                                                                                                                                          3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         2.                                                                                                                                                       1. 
                                                                                                                                                                                                                                                                                                                                                 Your current address:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              applicable questions:                   Check reason for “Final Return” and answer                                 were withheld _______________________                                         Last pay period on which Hamtramck taxes
                                                                                                                                                                      Other:                                                  City                                                       Street                                                                                                                                              Moved out of Hamtramck                                City                                                    Street                                               Name                                                                                          Business sold to:                       (Date)___________________________                       Wages will be paid starting                                        Still operating - Ceased paying wages.                                                                       (Date)___________________________                       Operations will be resumed on                                   Business temporarily discontinued                                   Business permanently discontinued 
________________________________                                 ________________________________
                                                                                                                                                                                                                              ____________________________                                                                                                                                                                                                                                         ____________________________
                                                                                                                                                                     __________________________                                                                                          __________________________                                                                                                                                                                                                                                        __________________________                           __________________________

                                                                                                                                                                     4.                                                                                                                                                                          3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         2.                                                                                                                                                       1. 
                                                                                                                                                                                                                                                                                                                                                 Your current address:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              applicable questions:                   Check reason for “Final Return” and answer                                 were withheld _______________________                                         Last pay period on which Hamtramck taxes
                                                                                                                                                                      Other:                                                  City                                                       Street                                                                                                                                              Moved out of Hamtramck                                City                                                    Street                                               Name                                                                                          Business sold to:                       (Date)___________________________                       Wages will be paid starting                                        Still operating - Ceased paying wages.                                                                       (Date)___________________________                       Operations will be resumed on                                   Business temporarily discontinued                                   Business permanently discontinued 
________________________________                                 ________________________________
                                                                                                                                                                                                                              ____________________________                                                                                                                                                                                                                                         ____________________________
                                                                                                                                                                     __________________________                                                                                          __________________________                                                                                                                                                                                                                                        __________________________                           __________________________

                                                                                                                                                                     4.                                                                                                                                                                          3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         2.                                                                                                                                                       1. 
                                                                                                                                                                                                                                                                                                                                                 Your current address:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              applicable questions:                   Check reason for “Final Return” and answer                                 were withheld _______________________                                         Last pay period on which Hamtramck taxes
                                                                                                                                                                      Other:                                                  City                                                       Street                                                                                                                                              Moved out of Hamtramck                                City                                                    Street                                               Name                                                                                          Business sold to:                       (Date)___________________________                       Wages will be paid starting                                        Still operating - Ceased paying wages.                                                                       (Date)___________________________                       Operations will be resumed on                                   Business temporarily discontinued                                   Business permanently discontinued 
________________________________                                 ________________________________
                                                                                                                                                                                                                              ____________________________                                                                                                                                                                                                                                         ____________________________
                                                                                                                                                                     __________________________                                                                                          __________________________                                                                                                                                                                                                                                        __________________________                           __________________________

                                                                                                 _______________________                       QUARTER ENDED DEC. 31                            ____________________ DECEMBER                              ____________________ NOVEMBER                            ____________________ OCTOBER                       _______________________                        QUARTER ENDED SEPT. 30                        ____________________ SEPTEMBER                             ____________________ AUGUST                            ____________________ JULY                           _______________________                       QUARTER ENDED JUNE 30                   ____________________ JUNE                               ____________________ MAY                          ____________________ APRIL                                                    _______________________                        QUARTER ENDED MARCH 31                                   ____________________ MARCH                          ____________________ FEBRUARY                                       ____________________ JANUARY                                        _______________________                                                                                    LIST PAYMENTS MADE WITH H941/501

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          EMPLOYERS RETURNS.
          TOTAL PAID $                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       SUMMARY

          __________

                                                                                                                                               $                                                                                                                                                                                                                                                                      $                                                                                                                                                                                                                                                                 $                                                                                                                                                                                                                                                                              $