Income Tax Return Year Form - City Of Mansfield - 2012

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CITY OF MANSFIELD
INCOME TAX RETURN
INDIVIDUAL
INCOME TAX DIVISION
YEAR 2012
P.O. BOX 577
FILE BY APRIL 15, 2013
G Refund
G Credit
MANSFIELD, OHIO 44901-0577
TELEPHONE (419) 755-9711
FAX (419) 755-9751
YOU MUST FILE AN INDIVIDUAL TAX RETURN – JOINT RETURNS WILL NOT BE ACCEPT
SOCIAL SECURITY # _________-_________-_________
____________________________________
Name
WERE YOU A MANSFIELD RESIDENT IN 2012?
YES
G
NO
G
__________________________________
Address
DATE MOVED INTO MANSFIELD _________________________
___________________________________
City
DATE MOVED OUT OF MANSFIELD _______________________
_______________________
________
State
Zip
DID YOU FILE A CITY RETURN LAST YEAR? YES
G
NO
G
G I am retired and have no taxable income – date retired _______________
G Active Military
G Unemployed
G Disabled
G I am under 18 years of age – Birth Date _______________ (Verification is needed)
G Social Security
G Pension
G I am at least 65 years of age, I receive a deduction of $6,350.00 on rental/or $2,500.00 on earned income
G I had no taxable income in 2012
FIGURE YOUR
1. TOTAL W-2 WAGES (W-2 BOX 18) (FROM WORKSHEET A) (Important: Attach all W-2’s) ………………………………………
$__________
TOTAL
2. 2106 EXPENSE ADJUSTMENT (FROM WORKSHEET A)………………………………………………………………………………………………………
$__________
INCOME
3. TAXABLE WAGES (SUBTRACT LINE 2 FROM LINE 1)…………………………………………………………………………………………………………
$__________
4. OTHER INCOME (FROM WORKSHEET B) (Attach All Schedules)……………………………………………………………………………………
$__________
5. TOTAL INCOME (ADD LINES 3 AND 4)…………………………………………………………………………………………………………………………………
$__________
6. ADJUSTMENTS (FROM WORKSHEET C)………………………………………………………………………………………………………………………………
$__________
7. MANSFIELD TAXABLE INCOME (SUBTRACT LINE 6 FROM LINE 5)……………………………………………………………………………………
$__________
FIGURE YOUR
8. MANSFIELD INCOME TAX (MULTIPLY LINE 7 BY .0175)……………………………………………………………………
$__________
TOTAL TAX
9. CREDITS: A. MANSFIELD INCOME TAX WITHHELD BY EMPLOYERS………………………………………………
$___________
B. ESTIMATED TAX PAYMENTS AND/OR PRIOR YEAR CREDITS……………………………………
$___________
C. INCOME TAXES PAID TO OTHER CITIES ( INSTRUCTIONS–Limit 1% OF Box 18)
$___________
D. TOTAL CREDITS (ADD LINES 9A THROUGH 9C)………………………………………………………
$___________
10. BALANCE DUE (SUBTRACT LINE 9D FROM LINE 8)…………………………………………………………………………
$___________
11. LATE FILING FEE $25.00 (IF FILED AFTER APRIL 15) ……………………………………………………………………
$___________
12. PENALTY/INTEREST (2% PER MONTH/AND OR PORTION OF MONTH IF PAID AFTER APRIL 15)
$___________
13. TOTAL DUE (IF LESS THAN $3.00-DO NOT REMIT) (ADD LINES 10, 11, 12) ………………………
$___________
OVERPAYMENT
14. OVERPAYMENT CLAIMED…………………………………………………………………………………………………………………
$____________
OR CREDIT
A. AMOUNT FROM LINE 14 TO BE REFUNDED……………………………………………………………
$____________
B. AMOUNT FROM LINE 14 TO BE CREDITED TO NEXT YEAR……………………………………
$____________
DECLARATION OF ESTIMATED MANSFIELD, OHIO CITY INCOME TAX FOR 2013
15. Total income subject to tax $ _________________ multiply by 1.75% (2013 tax rate) …………………………………………………………………………
$ ___________
16. Estimated credits (tax withheld, paid by partnerships, paid to other cities) ………………………………………………………………………………………………
$ ___________
17. Net Tax Due (line 15 less Line 16) …………………………………………………………………………………………………………………………………………………………………
$ ___________
18. First installment of declaration (not less than 22.5% of line 17) …………………………………………………………………………………………………………………
$ ___________
19. Less overpayment from line 14B above: ($__________________) = Balance due with return: ……………………………………………………………
$ ___________
20. TOTAL AMOUNT DUE (ADD Lines 13 and 19)……………………………………………………………………….. PAY THIS AMOUNT
$ _________
IF THIS RETURN WAS PREPARED BY A TAX PRACTITIONER, CHECK HERE IF WE MAY CFONTACT HIM/HER DIRECTLY WITH QUESTIONS REGARDING THE PREPARATION OF THIS RETURN.
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated and that the figures
used herein are the same as used for Federal income tax purposes. The return must be signed and dated.
_______________________________________________ ________________________
_______________________________________________ __________________________
SIGNATURE OF TAXPAYER (REQUIRED)
DATE
SIGNATURE OF PREPARER, IF OTHER THAN TAXPAYER
DATE
________________________________
______________________________________________ _________________________
PHONE #
EMPLOYER AND ADDRESS OF PREPARER
PHONE #

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