Form FR-900A 2012 Employer/Payor

*129000110002* 1/20/2013 2012 FR 900A 2012 FR 900A Employer/Payor Account Number Business name City State Zip Code +4 DC income tax withheld this DCW006A District of Columbia Due Date Fill in Fill in Fill in if FEIN Fill in if SSN Government of the if amended return if final return if non wage Mailing address line 1 OFFICIAL USE ONLY Taxpayer Identification Number Taxpayer s signature Title Date Paid Preparer s Signature Date This is a FILL IN format Please do not handwrite any data on this form other than your signature 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 Withholding Tax Annual Return year per W 2 s/1099 s Mailing address line 2