Vermont Department of Taxes PO Box 547 Montpelier. VT 05601-0547 Phone: (802) 828-2551 VT Form WHT-436 QUARTERLY WITHHOLDING RECONCILIATION and HEALTH CARE CONTRIBUTION Business Name Federal ID Number Address VermontAccouM ID City Slate ZIP Code For Department Use Only Foreign Country (It not United States) Reporting Period - Check only ONE. It due date falls on a weekend or holday, return is due • SEP Oct. 25) the next business day. Year L, g reported (TYYY) JAN-MAR APR -JUN JUL (due Av. 25) (due JIJI. 25) (due OCT-DEC (due Jan. 25) A. Number of full-time employees as of the last day of this quarter.. ..A. B. Number of part-time employees as of the last day of this quarter. ..B. C. Check here if this is an AMENDED return. C ❑ PART I WAGE WITHHOLDING 1. Total Vermont wages paid this quarter 1 2. Total Vermont tax withheld from wages this quarter 2 PART II NONWAGE WITHHOLDING 3. Total nonwage payments subject to withholding this quarter 3 4. Total Vermont tax withheld from nonwage payments this quarter 4. 5. Total Vermont tax withheld this quarter (Add Lines 2 and 4) 5 PART III HEALTH CARE CONTRIBUTIONS ❑ Check here to certify that no Healthcare Contribution is due. 6. Adjusted Uncovered FrE (from worksheet, Line D) . 6. 7. Total Health Care Contributions Due (from worksheet, Line E) 7 PART IV BALANCE 8. Total due (Add Lines 5 and 7) 8 9. Vermont withholding tax already paid this quarter 9. 10. Refund (if Line 9 is greater than Line 8, subtract Line 8 from Line 9) 10. 11. TOTAL Withholding Tax and Health Care Contributions Due (if Line 8 is greater than Line 9, subtract Line 9 from Line 8) IL PART V SIGNATURE I hereby certify that I have examined this return and to the best of my knowledge and belief it is true, correct, and complete. Sgnature of Officer et Authorized Agent Dale Title Telephone Number Prepares Signature Date Firms name (o yours, if self-employed) and address Check here if authorizing the VT ❑Department of Taxes to discuss this return and attachments with your prepare,. Preparers Telephone timber Preparers PTIN or EIN Form WHT-436 Rev. 1C:7 EFTA01219698