Form VSEW

EMPLOYERS QUARTERLY RETURN OF TAX WITHHELD

Instructions on Reverse      side of Taxpayers Copy

	Dollars		Cents	I hearby certify that the information and statments contained herein are true and correct
1. Taxable Earnings paid all Employees subject to Village Income Tax (Tax is 1.25%)	$			(Signed) _______________________________________
2. Actual Tax Withheld in Quarter for Village Income Tax	$			(Official Title) __________________________|_________
3. Adjustment of Tax for prior quarter (see instructions)				Date
4. Interest ___________________________________________				THIS RETURN MUST BE FILED ON OR BEFORE THE DUE DATE SHOWN BELOW
Total	$			MAKE CHECK OR MONEY ORDER PAYABLE TO:

Tax ID # _____________________________________   (Name of Company) ____________________________

FOR MONTHS OF DUE ON OR BEFORE

Mail to:  Village of Columbus Grove               Income Tax Dept.               113 East Sycamore St.               Columbus Grove, OH 45830

Notify Income Tax Department promptly of any change in ownership or name and address shown above

If receipt is desired, return Taxpayer's Copy of this    form and enclose self-addressed, stamped envelope.