Form Dir-38 - City Income Tax Return For Individuals - 2016 Page 3

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Name(s) as shown on Page 1

Primary Social Security Number

Stop:

If your only source of income is from wages, do not complete the remainder of this page. Return to Page 1. Copies of your Federal Schedules C, E and

F may be attached to your city return in lieu of completing the schedules below

Part E

SCHEDULE C - INCOME FROM SELF-EMPLOYMENT

Profit or Loss from Business (Sole Proprietorship)

If you conducted business in more than one city, you must allocate income on Schedule Y.

Business Name:

Business Address:

Nature of Business:

Employer ID Number, if any:

Has City income tax been withheld from and remitted for all taxable employees

Date Business Started:

During the period covered by this return?

Date City Business Began:

□ YES □ NO If NO, explain on an attached statement.

Accounting Method: □ Cash

□ Accrual

□

Other

Section 1

INCOME

1. Total Receipts Less Allowances, Rebates and Returns

2. Less (A) Cost of Goods Sold or (B) Cost of Operations, whichever is applicable

Enter Amount of Labor Costs included on Line 2 here ___________(attach 1099’s if issued)

3. Gross Profit Subtract Line 2 from Line 1

4. Dividends _____________+ Interest___________+ Royalties______________=

5. Rents Received (if connected with trade or business.

6. Other Business Income (attach schedule).

7. Gross Income. Add Lines 3 through 6.

Section 2

EXPENSES

Advertising & Promotion

14. Repairs

14.

Bad Debts

15. Salaries & Wages

15.

10.

Car & Truck Expenses

10.

16 Compensation of Officers

16.

17. Commissions (attach 1099’s if issued)

11.

Depreciation, Amortization, Depletion

11.

17.

12.

Interest of Business Indebtedness

12.

18. Taxes & Licenses

18.

13.

Rents (Paid to:_______________)

13.

19 Other: Attach Schedule

19.

20. Total Expenses. Add Lines 8 through 19

20.

21. Net Profit (or Loss) from Business or Profession. Subtract Line 20 from Line 7.

21.

Part F

RENTAL AND PARTHERSHIP INCOME

Section 1

INCOME OR LOSS FROM RENTAL REAL ESTATE

Property A

Property B

Property C

Property D

1. Address of Property

(include No. Street, City & State

2. Rents Received

3. Depreciation

4. Repairs.

5. Other Exp. (Attach Sched)

6. Net Income (Loss)

7. Local Tax Paid

8. Local jurisdiction paid

Section 2

PARTNERSHIP/OTHER INCOME Residents only. Attach Schedule E

Partnership/Source

Federal Identification #

Income Taxable to

Your Share to City

If applicable

What City

Taxable Income

Taxes Paid

The loss from an unincorporated business activity reported on this page may not be used to offset W-2 wages reported on Page 1. However, the loss from an unincorporated business

activity may be used to offset a gain from another unincorporated business activity if: both unincorporated activities are taxed by Dublin. NOTE: Remember to file your Declaration of

Estimated Taxes (Form DID-1) for the current year. Phone (614) 440-4460.