HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK
                            IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO        CITY OF HAMTRAMCK
                            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
                                                                                           TOTAL TAX WITHHELD 4
                                                                                           THIS QUARTER
                                                                                                              5
                                                                                           ADJUSTMENT
                                                                                           ADJUSTED TAX       6
                                                                                           WITHHELD
MAIL IN SUPPLIED ENVELOPE   PERIOD            DUE ON                 IDENTIFICATION NO.    AMOUNT             7
                            1-1-19 to 3-31-19 4-30-19                                      DUE

                            HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK
                            IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO        CITY OF HAMTRAMCK
                            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
                                                                                           THIS QUARTER
                                                                                                              5
                                                                                           ADJUSTMENT
                                                                                           ADJUSTED TAX       6
                                                                                           WITHHELD
MAIL IN SUPPLIED ENVELOPE   PERIOD            DUE ON                 IDENTIFICATION NO.    AMOUNT             7
                          4-1-19 to 6-30-19   7-31-19                                      DUE

                            HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK
                            IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO        CITY OF HAMTRAMCK
                            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
                          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
                                                                                           THIS QUARTER
                                                                                                              5
                                                                                           ADJUSTMENT
                                                                                           ADJUSTED TAX       6
                                                                                           WITHHELD
MAIL IN SUPPLIED ENVELOPE   PERIOD            DUE ON                 IDENTIFICATION NO.    AMOUNT             7
                          7-1-19 to 9-30-19   10-31-19                                     DUE

                            HAMTRAMCK INCOME TAX WITHHELD                                                      MAKE CHECK
                            IF FINAL RETURN, CHECK HERE AND COMPLETE                                           & MAIL TO        CITY OF HAMTRAMCK
                            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
                                                                                           THIS QUARTER
                                                                                                              5
                                                                                           ADJUSTMENT
                                                                                           ADJUSTED TAX       6
                                                                                           WITHHELD
MAIL IN SUPPLIED ENVELOPE   PERIOD            DUE ON                 IDENTIFICATION NO.    AMOUNT             7
                          10-1-19 to 12-31-19 1-31-20                                      DUE

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

                                                                                                                                                                                                                                                                                                                                                                                                                                   $                                                                                                                                                                                                                                                  $                                                                                                                                                                                                                                             $                                                                                                                                                                                                                                             $

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 __________

                                            SUMMARY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              TOTAL PAID $
                                                                                                                                                              EMPLOYERS RETURNS.

                                                                                  LIST PAYMENTS MADE WITH H941/501                                                                                    _______________________  JANUARY                           ____________________  FEBRUARY                          ____________________  MARCH                        ____________________                                   QUARTER ENDED MARCH 31 _______________________  APRIL                                  ____________________                             MAY ____________________                                   JUNE ____________________                       QUARTER ENDED JUNE 30 _______________________                            JULY ____________________                            AUGUST ____________________                              SEPTEMBER ____________________                         QUARTER ENDED SEPT. 30 _______________________                      OCTOBER ____________________                            NOVEMBER ____________________                             DECEMBER ____________________                           QUARTER ENDED DEC. 31 _______________________                                   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    __________________________                           __________________________                                                                                                                                                                                                                  __________________________                                                                                         __________________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ____________________________                                                                                                                                                                                                                  ____________________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ________________________________                                 ________________________________
                                                                                                                                                                                                                               Business permanently discontinued                       Business temporarily discontinued                      Operations will be resumed on                      (Date)___________________________                                                 Still operating - Ceased paying wages.                      Wages will be paid starting                          (Date)___________________________                            Business sold to:                                                  Name                                                 Street                                                 City                                                         Moved out of Hamtramck                                                                                                  Street                                                   City                                                       Other:
   Last pay period on which Hamtramck taxes were withheld _______________________                                  Check reason for “Final Return” and answer                   applicable questions:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Your current address:
   1.                                                                                                              2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              3.                                                                                                                                                                   4. 

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

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

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