Transaction No. 31 STATE FILING INFORMATION WORKSHEET Company Name Payment Frequency Employer Account # Gross Compensation Employer ID # PA Withholding Tax Employer Password Credits Quarter Ending Date Interest Telephone Number Payment Transaction No. 12 Monthly Wage Tax 1. TAX DUE PER WORKSHEET, Line GLO-BRITE PAINT COMPANY 2215 SALVADOR STREET PHILADELPHIA, PA 19175-0682 Account # 6791855 From: 10/01 2. INTEREST AND PENALTY Tax Type: 01 To: 10/51 3. TOTAL QUE (LINE 1 4 2 Period/Yr. 10/- Due Date: 11/16 Signature: T heraby cairlily Chal I hass scamined This mum Philadelphia Revenue Department P.O. Box 8040 Make checks payable to: Phone S: Philadelphia, PA 19101-8040 CITY OF PHILADELPHIA