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

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  JANUARY 1M
                                                                                                      DUE DATE                     February 28, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              2 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  FEBRUARY 2M
                                                                                                      DUE DATE                     March 31, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              3 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  MARCH 3M
                                                                                                      DUE DATE                     April 30, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              4 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  APRIL 4M
                                                                                                      DUE DATE                     May 31, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              5 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  MAY 5M
                                                                                                      DUE DATE                     June 30, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              6 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  JUNE 6M
                                                                                                      DUE DATE                     July 31, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              7 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  JULY 7M
                                                                                                      DUE DATE                     August 31, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              8 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  AUGUST 8M
                                                                                                      DUE DATE                     September 30, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

P - 941 City of Pontiac - Income Tax Division                                                                              9 M            2021
            Employer’s Return of Income Tax Withheld                                                Tax withheld                   ____________________________________
                                                               Make remittance payable to:
If this is your first return, enter date this                  Treasurer, City of Pontiac           Adjustments                    ____________________________________
business was started _______________________________           Mail to:
If this is final return, or employer status has changed,       City of Pontiac Withholding Payments Net tax withheld               ____________________________________
see back of form for required information to be submitted.     P.O. Box 530                         Late payment penalty - 1%
I certify the tax withheld as shown on this return is correct. Eaton Rapids, MI 48827-0530          per month ($2.00 minimum)      ____________________________________
                                                                                                    Interest due 
Signature _______________________________________________________  Date _________________           (contact city for daily rates) ____________________________________
Phone # ____________________________________________
                                                                                                    TOTAL DUE
                                                                                                    PAY THIS AMOUNT

                                                                                                    FEDERAL EMPLOYER ID #          ____________________________________
                                                                                                      TAX YEAR                     2021
                                                                                                     PAYROLL PERIOD  SEPTEMBER 9M
                                                                                                      DUE DATE                     October 31, 2021
                                                                                                                           
                                                                                                                         DO NOT WRITE BELOW THIS LINE

                                                                                                                                                                                                                                                                              Ceased paying wages

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

                                                                                                                                                                                                                                                                              Ceased paying wages

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

                                                                                                                                                                                                                                                                              Ceased paying wages

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