Form FR-900B 2012 Employer/Payor Withholding Tax Annual Reconciliation and Report

(if Line 1 is less than Line 2) (if Line 1 is more than Line 2) paid to DC this year on this year per W 2 s/1099 s *129000210002* *129000220002* 1 DC income tax withheld 2 Total withholding tax 2012 FR 900B Employer/Payor Withholding Tax Annual Reconciliation and Report 2012 FR 900B P1 2012 FR 900B P2 3 Additional Tax Due 4 Overpayment Account Number Due Date Business mailing address line 1 Business mailing address line 2 Business name Date Paid DCW007M DCW008M District of Columbia DOLLARS ONLY Employer s DC withholding tax reconciliation Explanation FEIN/SSN Fill in if Amended return Fill in if FEIN Fill in if SSN FOR OFFICIAL USE ONLY Forms FR 900M or FR 900Q FR 900B PAGE 2 Reconciliation and Report Government of the OFFICIAL USE ONLY Paid Preparer s Preparer s PTIN signature State Tax Paid Tax Period Ending (MMYY) Taxpayer Identification Number Taxpayer name Taxpayer s Telephone number of person to contact Title Total for the year Under penalties of law I declare that to the best of my knowledge this return is correct Declaration of paid preparer is based on the information available to the preparer Vendor ID#0002 Zip Code + 4