Income Tax Return - City Of Ashtabula - 2016
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1
2st
CHECK ALL THAT APPLY:
Individual
Proprietor
Partner/Partnership
Corporation
S Corp
LLC
Amended Return
1
time filer
REFUND
Primary SSN or
MAKE CHECK OR MONEY ORDER TO:
INCOME TAX RETURN
Federal ID
CITY OF ASHTABULA – TAX DEPT
2016
P.O. Box 601
Spouse SSN
ASHTABULA, OH 44005-0601
Phone: (440) 992-7104 Fax: (440) 992-7556
Phone No.
DUE DATE APRIL 18, 2017
Email:
Email Address:
MOVE IN
OUT
DATE:
(Fill in circle)
FORWARDING OR NEW ADDRESS:
FILE#
)
RETIRED AND TAXPAYERS WITH NO TAXABLE INCOME: REASON
(CHECK APPROPRIATE BOX TO INACTIVATE ACCOUNT
ACTIVE DUTY MILITARY
RETIRED WITH ONLY NON-TAXABLE INCOME
RETIREMENT DATE
TAXPAYER DECEASED
ONLY INCOME FROM NON-TAXABLE SOURCE; LIST SOURCE
STOP HERE: Sign and remit Form - supporting documents must be attached
WAGES – W-2 COPIES MUST BE ATTACHED – USE the HIGHER of W-2 (Box 5 AND 18) for wages
Employer/Work
W2 Wages
Ashtabula City Tax
Other City Tax
Location
(Box 5 or 18)
Withheld (Box 19)
Withheld (Box 19)
Pro-Rate for Partial Year
Pro-Rate for Partial Year
Pro-Rate for Partial Year Residents
Residents
Residents
TOTALS
1.
TAXABLE INCOME
A. Total - Wages, salaries, tips, etc.
$
B. Federal Form 2106 Deduction (if applicable) Attach 2106 Form along with Schedule A of Federal Tax Return
$
C. Adjustment from Page 2: Total of Line(s) 17 and 19 - Attach applicable Schedules
$
D.Gambling/Lottery Winnings ($2,500.00 and higher) Attach W2-G
$
E. TAXABLE INCOME (1A – 1B + 1C + 1D)
$
2.
Ashtabula Income Tax 1.8% of Line 1E or (1E X .018)
$
3.
CREDITS
A.
Ashtabula Income Tax withheld by Employer (s)
$
B.
Lesser of Other Cities taxes withheld
X 50% $
Enter the
Amount from Line 2 above
Amount from Line 2 above
X 50% $
X 50% $
$
$
Lesser amount
C. Estimated Tax Paid
$
D. Prior year Overpayment Applied
$
E.
Total Credits (Add 3A thru 3D )
$
4.
TAX DUE (Line 2 less 3E)
$
5.
PENALTY AND INTEREST
A.
Penalty (15%) of amount due by Dec 15, 2016 and not paid
$
B.
Late Filing Fee - After April 17, 2017 ($25.00 per month up to $150.00)
$
C.
Interest (.50% per month) - After April 17, 2017
$
D.
TOTAL DUE Tax ,Penalty & Interest (4 + 5A+ 5B+5C)
$
6.
OVERPAYMENT CLAIMED (if Line 6 is between negative .01 and negative 10.00 insert $0.00)
$
A.
Enter Amount of Line (5) Applied to 2017
$
B.
Enter Amount of Line (5) Refunded
$
7.
$
Amount Due (if Line 6 is less than $10.01 insert $0.00)
Note: Over payments of less than $10.01 shall not be Refunded /No Remittance is required for Taxes due of $10.00 or less
MANDATORY DECLARATION OF ESTIMATED TAX –
Taxpayer’s owing more than $200.00 are required to declare and pay estimated tax
8.
Estimate of Taxable Income for 2017
(A) $
X Ashtabula tax 1.8%
(B)$
9.
Estimate of Credits: (A) Local Income Tax Withheld
$
(B) Payments Applied (from Line 5A)
$
(C) Total Line (10A+10B)
$
(D) 2017 Declaration of Estimated Tax (9B less 10C)
$
10. Quarterly Estimate Due – Multiply Line 9D by .25
$
TOTAL AMOUNT DUE -
2016 $
(Line 6) + 2017 $
(Line 11)
Payment in full is due with return
____________________________________
__________
_________________________________
__________
Taxpayer’s Signature
Spouse’s Signature
Date
Date
Date
_______________________________________________________
_________________________________________________________
Tax Preparer’s Name & Signature
Tax Preparer’s contact information (phone/email)
Date
(We) authorize the City of Ashtabula Income Tax Dept to discuss my/our return and enclosures with the preparer above. Initial here______________
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