HIGHLAND PARK INCOME TAX WITHHELD                                                                                                         MAKE CHECK
                          IF FINAL RETURN, CHECK HERE AND COMPLETE                                                                                                     & MAIL TO  CITY OF HIGHLAND PARK
                          QUESTIONS ON THE REVERSE SIDE                                                                                  HP941-501                                        Withholding Payment
                                                                                                                                                   AMOUNT WITHHELD 1                          P.O BOX 239
                                                                                                                                                   1ST MONTH THIS QTR             EATON RAPIDS, MI 48827-0239
                          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
                          1-1-20 to 3-31-201-1-071-1-12toto3-31-123-31-07                4-30-204-30-074-30-124-30-12                              DUE

                            HIGHLAND PARK INCOME TAX WITHHELD                                                                                                         MAKE CHECK
                          IF FINAL RETURN, CHECK HERE AND COMPLETE                                                                                                     & MAIL TO  CITY OF HIGHLAND PARK
                          QUESTIONS ON THE REVERSE SIDE                                                                                  HP941-501                                        Withholding Payment
                                                                                                                                                   AMOUNT WITHHELD 1                          P.O BOX 239
                                                                                                                                                   1ST MONTH THIS QTR             EATON RAPIDS, MI 48827-0239
                          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
                          4-1-20 to 6-30-204-1-074-1-124-1-12to6-30-12to6-30-12to 6-30-077-31-207-31-127-31-197-31-07                              DUE

                            HIGHLAND PARK INCOME TAX WITHHELD                                                                                                         MAKE CHECK
                          IF FINAL RETURN, CHECK HERE AND COMPLETE                                                                                                     & MAIL TO     CITY OF HIGHLAND PARK
                          QUESTIONS ON THE REVERSE SIDE                                                                                  HP941-501                                        Withholding Payment
                                                                                                                                                   AMOUNT WITHHELD 1                          P.O BOX 239
                                                                                                                                                   1ST MONTH THIS QTR             EATON RAPIDS, MI 48827-0239
                          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
                          7-1-07 to 9-30-077-1-12 to9-30-12                              10-31-0710-31-12                                          DUE
MAIL7-1-20 to 9-30-20IN SUPPLIEDPERIODENVELOPE                                           10-31-2010-31-12DUE ON       IDENTIFICATION NO.           AMOUNT             7

                            HIGHLAND PARK INCOME TAX WITHHELD                                                                                                         MAKE CHECK
                          IF FINAL RETURN, CHECK HERE AND COMPLETE                                                                                                     & MAIL TO  CITY OF HIGHLAND PARK
                          QUESTIONS ON THE REVERSE SIDE                                                                                  HP941-501                                        Withholding Payment
                                                                                                                                                   AMOUNT WITHHELD 1                          P.O BOX 239
                                                                                                                                                   1ST MONTH THIS QTR             EATON RAPIDS, MI 48827-0239
                          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
                          10-1-20 to 12-31-2010-1-12 to12-31-12                          1-31-211-31-081-31-13                                     DUE

                            CITY OF HIGHLAND PARK–ANNUAL RECONCILIATION•INCOME TAX WITHHELD                                                                                                  HPW-3
                          DUE ON OR BEFORE                                                                            IDENTIFICATION NO.           RETURN WITH FORMS             TAX WITHHELD
                            February 28, 2008February 28,2013                                                                                      W-2 TO                        AS SHOWN ON
                                                                                                                                                   CITY OF HIGHLAND PARK         ATTACHED W2’S
                                                                                                                                                   INCOME TAX                    1
                                                                                                                                                   P.O Box 239
                                                                                                                                                   Eaton Rapids, MI 48827-0239    TAX PAID
                                                                                                                                                                                 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

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

                                                                                                                                                                                                  ____________________________                                                                                                                                                                                                                                              ____________________________
                                                                                                                                        __________________________                                                                                            __________________________                                                                                                                                                                                                                                             __________________________                           __________________________

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

                                                                                                                                                                                                  ____________________________                                                                                                                                                                                                                                              ____________________________
                                                                                                                                        __________________________                                                                                            __________________________                                                                                                                                                                                                                                             __________________________                           __________________________

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

                                                                                                                                                                                                  ____________________________                                                                                                                                                                                                                                              ____________________________
                                                                                                                                        __________________________                                                                                            __________________________                                                                                                                                                                                                                                             __________________________                           __________________________

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

                                                                                                                                                                                                  ____________________________                                                                                                                                                                                                                                              ____________________________
                                                                                                                                        __________________________                                                                                            __________________________                                                                                                                                                                                                                                             __________________________                           __________________________

                                                                                                                                                                                         DECEMBER                                                    NOVEMBER                                                  OCTOBER                                                                                                                                            SEPTEMBER                                                   AUGUST                                                  JULY                                                                                                                                      JUNE                                                    MAY                                              APRIL                                                                                                                                                                 MARCH                                              FEBRUARY                                                            JANUARY
                                                                    _______________________                       QUARTER ENDED DEC. 31                            ____________________                                        ____________________                                      ____________________                                _______________________                       QUARTER ENDED SEPT 30                            ____________________                                        ____________________                                    ____________________                                _______________________                       QUARTER ENDED JUNE 30                   ____________________                                    ____________________                             ____________________                                         _______________________                        QUARTER ENDED MARCH 31                                    ____________________                               ____________________                                                ____________________                                                _______________________                                                                                    LIST PAYMENTS MADE WITH HP941/501

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  EMPLOYERS RETURNS.
        TOTAL PAID $                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            SUMMARY

        ________

                                                                                                                  $                                                                                                                                                                                                                                                                        $                                                                                                                                                                                                                                                                      $                                                                                                                                                                                                                                                            $