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DETACH HERE BEfORE MAILING - Pennsylvania Department …

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DATE DAYTIME TELEPHONE # EXT. TITLE SIGNATURE ( ) REV-1667 (SU) 03-22 BUSINESS NAME AND ADDRESS LEGAL NAME TRADE NAME ADDRESS CITY, STATE, ZIPDO NOT SEND PAYMENT WITH THIS FORM. $ $ ENTITY ID (EIN)EMPLOYER ACCOUNT IDYEARDUE DATE JANUARY 311a Part I RECONCILIATION Part II ANNUAL RECONCILIATIONNumber of W-2 forms attached1bNumber of 1099 forms with PA withholding2Total compensation/distribution subject to PA withholding3PA personal income tax withheld Wages/distribution paid subject to PA withholding PA tax withheld 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL

DETACH HERE BEfORE MAILING PLEASE READ THE INSTRUCTIONS BEfORE COMPLETING THIS COUPON. INSTRUCTIONS fOR THE ANNUAL WITHHOLDING RECONCILIATION STATEMENT (REv-1667) The Annual Withholding Reconciliation Statement (REV-1667) along with an individual Wage and Tax Statement/Information Statement (W …

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