BACADCBAADADADADBAAC 41129913 Mark an X in only one box to indicate the quarter (a separate return must be completed for each quarter) and enter the tax year. 1 1 2 Jan 1 Mar 31 Withholding identi cation number Print 1 223456789 Apr 1 Jun 30 3 4 July 1 Sep 30 Oct 1 Dec 31 Y Tax year Employer legal name: Are dependent health insurance bene ts available to any employee? ..................... Yes THE CORNER STORE For of ce use only Y Postmark 12.
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