WITHHOLDING CERTIFICATE – DENVER OCCUPATIONAL

WITHHOLDING CERTIFICATE – DENVER OCCUPATIONAL PRIVILEGE TAX
This form is furnished to and is to be completed by the principal employer upon request by an employee.
COMPLETE SECTIONS A and B if you have an employee who has a secondary employer from whom he receives
$500.00 or more per month. The secondary employer’s copy may be delivered to him by the employee. The
employee must sign the bottom of the secondary employer’s copy each month. The secondary employer must
retain the withholding certificate for a three year period.
COMPLETE SECTIONS A and C if you have an employee who is leaving your employ and ALL THE FOLLOWING
CONDITIONS EXIST:
1. His/Her termination date is other than the end of a calendar month;
2. You have withheld the tax for such month and;
3. He/She anticipates receiving more than $500.00 during such month from his/her next employer.
SECTION A
I certify that __________________________________________________________________ is an employee
Last Name
Middle Init.
First Name
of ________________________________________________________________________________________.
Firm Name and Address
We are his/her principal employer and …. (Complete B or C below.)
SECTION B
We will withhold the Denver Employee Occupational Privilege Tax beginning with the month of
________________, 20______, and each taxable month thereafter while in our employ.
SECTION C
We have withheld the Denver Occupational Privilege Tax for the month of _______________, 20_______.
____________________________________
Date
___________________________________________
Authorized Signature
I declare, under the penalties of perjury, that my principal employer, as designated on the face of this certificate,
has withheld the Denver Occupational Privilege Tax for the following periods:
Month
Year
Signature
Month
Year
Signature
TD 269 (4/04)